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“I know everything that I need to know about Medicare.” —No one

“I’m all set.” —Too many

All net proceeds will be donated to the Great Humanity Healthcare Foundation (


Understanding Medicare, Protecting Your Health, And Minimizing Costs

(2018 EDITION)

by Jae W. Oh, MBA, CFPTM

© 2017 by Jae W. Oh, MBA, CFP™, CLU® ChFC®. All rights reserved. No part of this book may be reproduced in any written, electronic, recording, or photocopying form without written permission of the author or the publisher. Print Format Publisher: GH2 Publishing Group, LLC e-book Format Publisher: GH2 Publishing Group, LLC Cover Art: Ani Cho Stone Library of Congress Cataloging in Publication Data Oh, Jae W. Maximize Your Medicare (2018 Edition): Understanding Medicare, Protecting Your Health, and Minimizing Costs / Jae W. Oh, CFP®, CLU® ChFC® Library of Congress Control Number: 2017963953 ISBN-13: 978-0-9967987-6-1 ISBN-10: 0-9967987-6-5 eISBN-13: 978-0-9967987-7-8 1. Medicare –Popular--works Notes: Includes Index and bibliographical references 10 9 8 7 6 5 4 3 2 1 DISCLAIMER: All statements in this book are solely the informed opinion of the author. The advice in this book cannot and does not represent financial or investment advice. Such advice requires a deep understanding of a person›s specific circumstances. Rather, this book provides examples of situations that are designed to provoke further inquiry by readers to help them understand how to best make Medicare work for them. Although the author has made every effort to provide accurate facts regarding Medicare, including the regulations that govern it, the author accepts no responsibility for any errors or omissions. The opinions stated in this book are not affiliated with, nor endorsed by, the Centers for Medicare and Medicaid Services (CMS). Printed in the United States of America.

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CONTENTS  Preface.......................................................................................... xiii Medicare is Confusing But Vital....................................................xiii Why is Medicare So Complicated?................................................. xiv Medicare is the Least Expensive Health Insurance........................... xv Will Repealing the PPACA Affect Medicare?................................. xvii Medicare Must Change................................................................. xvii How to Use This Book................................................................. xviii

Chapter 1: Enrollment in Medicare.................................. 1 Medicare Eligibility...........................................................................1 Enrollment Prior to 65 (ALS, ESRD, Disability)...............................3 Can I Delay Enrollment If I Work?...................................................4 Late Enrollment Penalty....................................................................6 How Much Is the Part B Late Enrollment Penalty?............................7 If You Are Penalized..........................................................................7 Financial Assistance...........................................................................8 PPACA Does Not Affect Medicare Enrollment.................................8

Chapter 2: Medicare Part A (Hospital Insurance)........... 11 Premium.........................................................................................12 Part A Benefits................................................................................13 Part A Inpatient Hospitalization Deductible....................................14 Copays............................................................................................15

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Key Term: Benefit Period................................................................15 Skilled Nursing Facility Care (SNF)................................................16 Observation Status..........................................................................17 No Annual Out-of-Pocket Expense Limit.......................................18 Table 1.  Medicare Part A Cost Sharing (2018)...............................19

Chapter 3: Medicare Part B (Medical Insurance)............ 21 Premium.........................................................................................21 Annual Deductible..........................................................................22 Coinsurance....................................................................................23 Key Term: Medicare-Allowed Charge..............................................23 Part B Excess Example.....................................................................25 Cancelling Medicare Part B.............................................................26 PPACA (“Obamacare”) and Medicare Part B..................................27 No Maximum Out-of-Pocket Expense Limit...................................27 Table 2. Medicare Part B Premium (2018).....................................28

Chapter 4: Medicare Part D (Prescriptions)................... 29 Enrollment......................................................................................29 Premiums........................................................................................30 Why People Misunderstand the Coverage Gap................................31 Choosing the Right Plan.................................................................32 Preferred Pharmacies and Mail Order..............................................34 Changing Plans...............................................................................35 The Coverage Gap (“Donut Hole”) and You...................................35 Employer Group Plans and the Coverage Gap (“Donut Hole”).......36 — viii —


Extra Help Program........................................................................38 Money-Saving Tip #1 and 2018 Update..........................................39 Money-Saving Tip #2: Check Pharmacies Carefully........................40 Table 3. Medicare Part D Premiums (2018)....................................41

Chapter 5: Medicare Part C (Medicare Advantage)......... 43 Enrollment......................................................................................44 Types of Medicare Advantage Plans.................................................48 Medicare Advantage Prescription Drug Plans (MAPD)...................50 Premiums........................................................................................51 Deductibles and Coinsurance..........................................................52 In-Network vs. Out-of-Network.....................................................52 Annual Notice of Change (ANOC) ...............................................54 How to Compare Medicare Advantage Benefits..............................55 Money Saving Tip #1 Medicare Advantage......................................57

Chapter 6: Medigap (Medicare Supplemental)............... 59 Medigap Enrollment.......................................................................60 Enrolling in Medigap During Other Periods...................................61 How Medigap Works with Original Medicare.................................63 Base Case: Medigap is Superior.......................................................67 Advantages of Medigap...................................................................68 When Is Medicare Advantage Better Than Medigap?.......................72 Money-Saving Tips on Medigap .....................................................75 Pitfalls to Avoid When Choosing a Medigap Policy.........................77 How to Avoid Pitfalls......................................................................79 — ix —

Medigap Restructuring Has Occurred in the Past............................80 Table 4. Medigap Plans�����������������������������������������������������������������82

Chapter 7: Employer (Group) Plans............................... 85 Can I Delay Enrollment in Medicare?.............................................85 The General Case............................................................................86 Pay Careful Attention to Enrollment Issues.....................................90 Examine Cost Sharing Terms Carefully...........................................92 Employer-Sponsored Medicare Advantage.......................................97 Dental, Vision, and Other “Benefits”..............................................97 What Employers Can Do................................................................98 Obamacare and Employer-Sponsored Plans...................................100

Chapter 8: Special Groups............................................ 103 Veterans Administration (VA).......................................................103 Federal Employee Health Benefits (FEHB) Program.....................107 State and Local Government Employees........................................109 Unions..........................................................................................111 Disabled and Employer-Sponsored Plan........................................112 ESRD and COBRA or Employer-Sponsored Plan.........................112 Hospital (and Other Healthcare) Employees.................................113 Small Business Owners..................................................................113 Professional “Associations”.............................................................115 Seriously Ill...................................................................................116 Diabetes........................................................................................117



Chapter 9: Related Topics............................................. 121 Medicare Will Evolve and You Must Adjust...................................121 Health Insurance and Life Insurance Are Related..........................122 Home Health Care and Nursing Homes.......................................125 What is Universal Life Insurance?..................................................127 Extended Benefits & Life Insurance..............................................127 Advertisements: Treasure or Trash?................................................128 Agents: Angels or Devils?.............................................................130 Final Thoughts..............................................................................132

Glossary........................................................................ 137 Bibliography................................................................. 145 Acknowledgements....................................................... 149 Index............................................................................. 151 Experts’ Addenda.......................................................... 155 Insurance Is An Option ................................................................155 Health Insurance Is Different........................................................155 Options Are Priced Using Probability............................................156 Everyone is “Short” an Option......................................................157 Comparing Apples to Apples.........................................................159 Medigap vs. Medicare Advantage Revisited...................................160

About the Author.......................................................... 163

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PREFACE  Medicare is Confusing But Vital Medicare, along with Social Security, is the cornerstone of retirement planning in the United States. Understood correctly, you will be able to control your total healthcare costs as you become older, the time when it is most likely you require medical care. If Medicare is mishandled or neglected, you may face unexpected costs, with little or no idea of how high your costs will be, or how long that situation will last. If you are penalized for mishandling enrollment, these penalties never expire. Fear of unknown costs can lead people to avoid getting medical attention: we all know someone that has chosen this regrettable path. Worse, avoiding needed medical attention can lead to even higher costs in the future. If that person does not have adequate insurance, and does not have the resources to pay, then the doctor, hospital, or healthcare provider is left with unpaid bills. As a result, the vicious cycle of higher healthcare costs accelerates. Maximize Your Medicare is written so that you can understand the rules that govern Medicare. More importantly, Maximize Your Medicare will help you understand the ripple effects of the choices that you are making. Admittedly, these ripple effects of your choices may be unseen today. Nevertheless, the fact that the future is unknown is not a reason for being uninformed about Medicare. That would be similar to ignoring hurricane forecasts, even if ultimately, the hurricane swerves harmlessly away from your home. There is a long list of excuses for not fully understanding Medicare. •

Confusing enrollment dates


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Advertisements and commercials


Complaints by colleagues and friends

The reality is that the commercials and advertisements are factually accurate, but the explanations are either absent, or incomplete. Medicare and You, the official manual published by the U.S. Government, is also insufficient for this same reason. Critically, the jargon of Medicare looks the same as the language used in other health insurance, but it can work differently from health insurance before someone turns 65 years old. Maximize Your Medicare is a guide to help you clarify the confusion, so that you can understand what your costs can be when you choose a specific Medicare configuration. Why is Medicare So Complicated? In the U.S., there are over 58,000,000 people that are enrolled in Medicare, and every day, approximately 10,000 turn 65 years old. Every single day. Improvements in medical knowledge and technology have resulted in longer life expectancy of the largest generation known to the United States. The bottom line is that in a country as large as ours, with people from different backgrounds, it will be virtually impossible to find a simple, easy solution. This is not going away. While elected officials may attempt to say that a political party is to blame, demographic facts overwhelm politically-motivated messages. On top of this, employer-provided health insurance plans have weakened, or have entirely disappeared. There is very little that the Medicare-eligible population can do about these dynamics. All participants in the healthcare system face a very complicated set of factors. Physicians, pharmaceuticals, hospitals, equipment makers, insurance carriers: this is only a partial list. All parties are facing a complicated set of rules and financial pressures. The challenge: beneficiaries (you) are left to “fend for yourself ” in this maze.

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The bright side is that you can find a solution that fits your individual health and financial situation. The enrollment rules are overwhelmingly in your favor. Insurance companies do not have discretion (except in the case of applying for Medigap after 65.5 years old, and the absence of a Special Enrollment Period): they are required to strictly follow the rules. In addition, there is fierce competition among insurance carriers, which can succeed only if they win your business. Medicare is the Least Expensive Health Insurance The idea that Medicare is expensive is usually the result of a person being unaware of the actual cost of health insurance. Health insurance for a 64 year-old, with benefits that resemble anything close to original Medicare, with either a Medicare Advantage plan (described in Chapter 5) or Medigap policy (described in Chapter 6), would cost well over $1,200 a month. In addition, that pre-Medicare health insurance policy would have a deductible (easily more than $1,000 a year) and copays. Prescription coverage would be included, but in many cases, the deductible would have to be met first. Under Medicare, your costs will likely decline, and the quality of your coverage will likely improve. For most people, original Medicare, (Medicare Part A and Medicare Part B) costs $134.00 for new enrollees. The average standalone prescription drug plan will cost an average of $35.03 per month in 2018.  Additionally, a 65-year old can purchase a policy, with no network, no deductible, and no concept of annual out-of-pocket maximum (because coinsurance will be $0), for about $150 a month.  The two premiums (Medicare Part B and Medigap) define your entire medical cost (not including prescriptions). In short, equivalent coverage is available under Medicare for much less than the cost of health insurance before a person becomes eligible for Medicare. The total cost difference can be thousands of dollars a year when a person becomes a Medicare beneficiary.

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Some may say “Currently, I only pay $300 a month.” That is because someone else (an employer or the younger employees in the group) is subsidizing you.  It has nothing to do with Medicare. It is very convenient to attempt to identify one “culprit.” In this case, Medicare is not to blame. In addition, those benefits programs include cost-sharing details (deductibles, copays, coinsurance), which are weakening over time. These are not aggressive estimates.  Th ey are re al-life, market-relevant numbers. If anything, Medicare beneficiaries should want Medicare to stay in its existing state, and to not weaken further from here.  When you think about the fact that Medicare can change, and largely for the worse, then you can understand the #1 recommendation of this book: Get the best coverage that you can reasonably afford, while you can, because your choices are probably going to worsen, due to your increasing age, declining health, and changing Medicare system. The changes that have been announced since the first edition of Maximize Your Medicare make this statement self-evident. This trend can be reasonably expected to continue. All three of the factors (age, health, changing Medicare system) are beyond your control. The only question is when, not if, these changes will affect your healthcare costs. Financial planning requires the understanding, and the acceptance, of risk. The perspective represented in Maximize Your Medicare is clear: the consumer has the prerogative to accept risk because consequences (which can be beyond your control) have dictated that to him/her, but that is entirely different from accepting risk that a person did not intend.  This book reveals some of the most important risks you may be taking, risks that you didn’t know you were taking. You can find recommendations that can help avoid unintended risks. There is the age-old cliché that says that “you hope for the best and plan for the worst.” Medical insurance under original Medicare, when com-

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bined with a Medigap policy (also known as Medicare supplemental insurance, a Medicare supplement), allows you to do this. You can largely protect against the most likely expense you will encounter as you naturally age, the most likely expense to cause you and your spouse/family worry, and the most likely source of financial distress to you and your extended family.   Will Repealing the PPACA Affect Medicare? It is almost impossible to predict what the ripple effects of a potential appeal of the PPACA (Obamacare) will be, but uncertainty resulting from the 2016 federal election will most likely result in higher hospital costs if the individual mandate is repealed. To review, the individual mandate is the requirement for all people to be covered by health insurance, or pay a penalty to the IRS. If this requirement no longer exists, the only logical conclusion is that the number of uninsured patients will rise. The result of this is the sum of unpaid bills, left at the hospital or healthcare provider, will also rise. That total bill must ultimately be paid, by someone. As of this writing, it is unclear whether the individual mandate, or other aspects of the PPACA, such as Medicaid expansion, will change, and the central question will be “how will the law change, and what will the replacement be?” The example above suggests that the ripple effect of a full repeal, if not replaced with a viable alternative, can have very negative effects on Medicare beneficiaries. Medicare Must Change Every year since the first edition of this book, Medicare has changed. For new Medicare beneficiaries, those first enrolling in Part B, the premium will increase from $121.60 to $134.00 a month. Those who earn more than $85,000 a year ($170,000 for married couples) will face higher surcharges, as anticipated by previous editions. This has been made more

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complicated by the fact that IRMAA for Part D is now different than in the past. The bottom line here is that as the population of Medicare-eligible increases, the costs to the Medicare system are also increasing, which is being made more extreme by the fact that people live longer now than they have in the past. While the changes may seem minor, that does not mean that anyone should expect the situation to remain stable. Demographic and fiscal challenges will, invariably, remain. Maximize Your Medicare will evolve with it. You can go to the website to find updates, corrections and additional examples of “This Happens.” Upon examination of the Medicare Advantage plans and Part D announced for 2018, Part D, has become increasingly complicated, even when the prescriptions taken remains the same. The late enrollment penalty has increased, premiums are higher, copays are more expensive, and formularies (approved drug lists) are constantly changing. Finally, competition among carriers is intensifying, which means that consumers can save money by examining which plan is best, given their prescriptions. Further changes to prescription drug plans should be expected as the Coverage Gap (otherwise known as the “donut hole) continues to narrow. How to Use This Book What you select will depend on the complicated combination of your medical situation, financial resources, family situation, and in the end, your mental outlook. This book may convince you that your situation is too complicated to decide for yourself. As a result, reading this book may encourage you to seek outside assistance. Even if this is your best option, this book will still be useful because it will help you ask informed questions, to make sure that you have considered the most important factors when making a decision. This book will help you judge whether or not the advice you are receiving is credible.

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While it is understandable that consumer fatigue due to mail, commercials, and advertisements may be justified to some degree, “tuning out” isn’t really a viable approach, because the consequences of not being fully informed are enormous. The book contains many examples of real-life situations. They are called “This Happens.” They are real-life examples (the names have been removed). Here is a quick sample: This Happens. Mr. Brown is retired from a large employer, and covered by his employer-sponsored retiree health benefits plan. He continues to stay covered by his retiree health benefits plan, for himself and his spouse, even though the cost of coverage is $600 a month, and has coverage that is inferior to original Medicare, in combination with either a) a Medicare Advantage plan or b) a Medigap plan and stand-alone prescription drug plan (Part D). This Happens. Ultimately, this book wants to help you avoid this oft-repeated conversation: A. “Why didn’t you tell me?” B. “You didn’t ask.” A. “Well, I didn’t know where to start to ask.” This book will point out factors which should be used in making a decision. While the situations presented cannot possibly be exactly like yours, they are meant with one message in mind: you are not alone, and there is always a way to choose amongst a seemingly dizzying number of options.  Maximize Your Medicare sets out to help you do just that.  — xix —


 ENROLLMENT IN MEDICARE Truths and Myths Truth: Your effective date for Part A, Part B, and Part D is usually (exceptions exist) the 1st of the month that you turn 65 years old. Truth: If you delay Part B and/or Part D enrollment, there are Late Enrollment Penalties that never expire. Myth: You can delay enrollment in Medicare for a while, enroll later, and Medicare will be immediately effective. Medicare Eligibility There are many different dates moving around, confusing terms with respect to eligibility, when to sign up, when there are penalties, and when there are not. Let’s start with the base case.  The base case: the initial Medicare Part A and Medicare Part B effective date will be the first day of the month that you turn 65 years old. This is the first date that you can be covered under Medicare Part A, Part B and Part D. For example, let’s use the name Jane Doe. If Jane was born on February 13, 1948, then she will be eligible to enroll in Medicare, which will begin on February 1, 2013.  There is an exception to this rule, which occurs for those born on the first day of any month. If Jane was born on February 1, 1948, for example, the first date of Medicare eligibility is actually going to be the first date of


the prior month. In this case, Jane’s first date of Medicare eligibility will be January 1, 2013. Signing up for Medicare Part A and Part B is usually quite a simple matter. If you are already receiving Social Security, or RRB (Railroad Retirement Board), benefits when you turn 65 years old, then you will automatically get your Medicare card, the well-known red, white, and blue card, with first date of eligibility printed right on it for you. The card looks like this:

Note: this card is scheduled to be replaced, with one that looks like this. It will no longer have your Social Security number as the Medicare Number. We will still use Jane Doe’s information in the examples.



For Jane Doe, let’s continue to use February 13, 1948, as Jane’s birthday. In this case, the first date that she can enroll is November 1, 2012, which is three months prior to her initial eligibility date. That is the first date that she can sign up for Medicare; remember that her effective date will not be until February 1, 2013. You can choose to not enroll in Medicare Part B until three months after the month that you turn 65 years old, and face no penalty. Let’s return to Jane. She turns 65 years old in February. Add three months to that. Jane can enroll in Medicare all the way up until May 31, 2013 without penalty. The period from November 1, 2012, through May 31, 2013, is commonly known as the Medicare Initial Enrollment Period.  Very important note: if you wait until the month of your 65th birthday, or later, then your Medicare Part B effective date will be delayed. If Jane signed up in February, the first date of coverage would be March 1. If Jane signed up in March, then the first date of coverage would be May 1. If Jane signed up in April, then the first date of coverage would be July 1. Lastly, if Jane signed up in May, then the first date of coverage would be August. Confused? The easiest solution: enroll during the month prior to your first possible Medicare Part B eligibility date. Enrollment Prior to 65 (ALS, ESRD, Disability) Some people are eligible for Medicare prior to turning 65. Here are the situations when a person, not yet 65 years old, can be eligible for Medicare. Amyotrophic Lateral Sclerosis, ALS (Lou Gehrig’s disease), patients are eligible for both Medicare Part A and Medicare Part B prior to turning 65 years old. End Stage Renal Disease. ESRD patients requiring dialysis are immediately eligible for Medicare. If you have ESRD, please refer to the Glossary for a very important fact about renal disease patients. The challenge is to understand how to minimize out-of-pocket expenses under dialysis, and is addressed in Chapter 8. —3—

Social Security Disability Insurance. If you are awarded Social Security Disability Insurance benefits, then you will be automatically enrolled into Medicare Part A and Medicare Part B after 24 consecutive months of receiving Social Security disability payments. On the first day of the third year that you receive Social Security Disability Insurance benefits, you will be automatically enrolled in Medicare Part A, and will be eligible for Medicare Part B. Depending on your net worth and income, you may also be eligible for the Low Income Subsidy (LIS, also known as the “Extra Help” program) at that time.  There is more information regarding the Extra Help program in Chapter 5. One thing to note: military disability is not the same thing as Social Security disability.  For example, there is no such thing as partial Social Security disability, as there is under the rules established by the Veterans Administration.  In addition, the process of obtaining VA disability benefits is entirely different from the process of applying for Social Security disability benefits. Can I Delay Enrollment If I Work? It is a very commonly asked question: do I have to enroll if I am currently covered by my current/former employer? The answer is that it will depend on your employment status, the size of your current/former employer, and in some cases, the employer’s discretion. So, the answer is yes, but that will depend on a number of different factors. This is addressed in Chapter 7. As the workforce ages, and people work until later ages in life, this question will become more popular, especially if original Medicare cost-sharing details (deductibles, copays of Part A and Part B) weaken. That is not the only input. The cost charged by employers to cover the Medicare-eligible is also rising, the terms and conditions of the coverage is weakening. This combination has dramatically changed the decision-making process. Employers and employees routinely make very expensive errors by not understanding the cost and benefits of Medicare. These errors cost the —4—


employer and the employee alike. Can I Delay Enrollment If I Retire? If you and/or your spouse were covered by an employer-provided group plan, and you retire, then you have an 8-month enrollment period in which you can enroll in Part B without penalty. This is useful for those who work where retiree health benefits are not provided. If your position has been eliminated, then you may be eligible for COBRA. Mistakes are common here, because people try to “play cute” and delay enrollment until the last possible date. While it is the right of the beneficiary to decide for himself, it is delicate because the possibility of error certainly exists. There are very specific dates, and rules regarding re-enrollment if you change your mind, which all must be completely understood, in advance. Discovering the truth, after the fact, exposes you to unknown ripple effects, and should be avoided, if at all possible. COBRA Works for 8 Months Only COBRA allows those who cease working for an employer to continue participation in group health insurance plans. That does not mean that COBRA can be used to delay enrollment in Medicare beyond the 8-month special enrollment period mentioned in the prior paragraph. COBRA can be used during the 8-month period, when you can delay enrollment in Part B without penalty. Note: it is not clear why someone would use COBRA, since COBRA premiums are much higher than original Medicare, and usually higher than plans under the PPACA. There are exceptions, which include if the prior employer-provided severance pays the COBRA premium, or if you have already paid the annual outof-pocket maximum on your existing plan. COBRA cannot be used as the reason to delay enrollment in Medicare beyond the 8-month period. Relying on COBRA beyond this 8-month period will result in Part B and Part D Late Enrollment Penalties, and you will not be able to enroll until the General Enrollment Period. —5—

If your deadline passes, then you will need to enroll in Medicare Part B during the General Election Period, which runs from January 1 through March 31, and your coverage will begin on July 1, and you will be subject to the late enrollment penalty, described earlier. This Happens. A spouse (male) is covered under his working spouse’s group health insurance. The working spouse ceases working, and they both continue being covered under COBRA laws. They continue coverage under COBRA laws for the full 18 months allowable under the law. The husband then attempts to enroll in Medicare Part B, only to find that he must wait until the General Election Period, and will be subject to a late enrollment penalty. This Happens. Late Enrollment Penalty Let’s now consider the case if you decide to not enroll in Medicare Part B during the Medicare Initial Enrollment Period. Back to Jane Doe, who was born on February 13, 1948.  Now, say it is August 15, 2013.  For every 12-month period, Jane Doe will pay a penalty for every year that she does not enroll in Medicare Part B. You might think that she could’ve simply signed up, and Medicare Part B would be effective September 1, 2013, right? Wrong.   When you do not enroll in Medicare Part B during the Medicare Initial Enrollment Period, and have no health insurance coverage, then the next time that you will be allowed to enroll is called the General Election Period (GEP), which runs from the beginning of January through the end of March every year. The effective date of coverage under Medicare will not begin until July 1 of that year, which means that you will need to wait, at precisely the wrong time.



Once you are a penalty-paying beneficiary, then your first effective date of coverage under Medicare can only be July 1. You will need to check with your Social Security office in order to confirm the first date that Medicare Part B will be effective. To make matters worse, you would be charged a rate that includes a penalty for not enrolling during your Medicare Initial Enrollment Period. The length that this penalty lasts: forever. How Much Is the Part B Late Enrollment Penalty? If you are subject to a Medicare Part B Late Enrollment Penalty, the amount is 10% of the Part B premium, multiplied by the number of 12-month periods that have passed since the last date that you could have enrolled in Part B under the Initial Coverage Election Period. For example, if you have delayed enrollment in Medicare Part B for two years after the end of your Medicare Open Enrollment Period, then you would be subject to a 20% penalty every month. This penalty never expires. If you are subject to a Medicare Part D Late Enrollment Penalty, the amount is 1% per month that passes after your Initial Election Period expires. There is an example of the calculation, described in Chapter 4. If You Are Penalized If you are penalized for late enrollment for Medicare Part B, there is still an important step to take. During the Annual Election Period, which occurs between October 15th and December 7th, you can (and should) select a stand-alone Prescription Drug Plan (Medicare Part D, described in Chapter 5). If you do not, the separate Part D late enrollment penalty will continue to accumulate until you have creditable prescription drug benefits. The way to avoid additional Part D late enrollment penalties is to enroll in a standalone prescription drug plan during the Annual Election Period, or Medicare Advantage plan that includes prescription drug benefits.


Financial Assistance If you cannot afford to pay Part A and/or Part B premiums, then you should contact your state’s Medicaid office. The Medicare Savings Program (MSP) is a broad term, and there are three different categories. They are Qualified Medicare Beneficiary Program (QMB), Specified Low-Income Medicare Beneficiary Program (SLMB), and Qualified Individual Program (QI). Each program (QMB, SLMB, QI) has different income level tests. Depending upon the program, assistance is available towards premiums, copays, and deductibles. In addition, a specific state may waive certain requirements, at its own discretion. In order to qualify, you need to contact your state’s Medicaid office. There is a separate assistance program for prescription drug benefits, called “Extra Help,” and also is known as the Limited Income Subsidy (LIS). This is described in Chapter 4. If you qualify for any of these programs, then you are always allowed to change your Medicare Advantage or Medicare Part D configuration, because you qualify for a Special Enrollment Period (SEP). The implication is that participation in these programs allows a person to ignore all annual enrollment periods. Special note, if you qualify as a QMB, SLMB, or QI beneficiary, or if you qualify for the Extra Help program, then all late enrollment penalties are waived. PPACA Does Not Affect Medicare Enrollment This fundamental question is asked by many, and the answer is not simple. First, the fundamental structure of Medicare is not different. The general cases described in this book will remain the same. There will be some changes to the decision-making process for those that are married and receive retiree benefits from an employer, as described in Chapter 7. If anything, those changes are very positive. The permanent “doc fix” does change



some subtle points about the timing and availability of choosing certain Medigap policies. There are also some subtle, but important, changes that may affect small-business owners if they are Medicare beneficiaries. Enrollment in Medicare and selection of Medicare Advantage or Medigap does not depend on the well-publicized Marketplace (http://www. You need not visit the site if you are a Medicare beneficiary. The general question regarding whether or not the Affordable Care Act is the root or solution to all evil will remain a political (and judicial) lightning rod used by elected officials for their own reasons. It will be almost impossible to quantify how much of the increased cost is due to the ACA, and how much is due to demographic reality. Rather than confuse the issue, the fact is that the demographic and fiscal challenges to the system will remain, and that beneficiaries should protect themselves, by themselves. Absent a “silver bullet” which probably does not exist, it will be a senior’s responsibility to fully understand Medicare and the implications of the choices that he/she is making.


NOTES PAGE ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������


 MEDICARE PART A (HOSPITAL INSURANCE) Truths and Myths Truth: Medicare Part A has no premium but has very expensive deductibles and copayments if you are hospitalized. Truth: The Part A deductible is not an annual deductible. It is a deductible that applies for each benefit period (explained here). Benefit period is not the same thing as an annual period. Truth: There is no annual maximum out-of-pocket limit. Myth: You have to meet an “improvement standard” to receive skilled nursing care. That is no longer the case. Misunderstanding of Medicare Part A is one of the largest sources of confusion regarding Medicare. Confusion over how Medicare Part A works leads to unanticipated bills, many of which could have been reasonably avoided. Worse, Medicare beneficiaries make financial and health decisions, based on faulty understanding. Medicare Part A can be thought of as coverage for the cost of facilities. A summary of the charges for Medicare Part A are provided in Table 1 at the end of this chapter (source: Make sure that you know and understand the definition of the terms deductible and copays before proceeding. They can be found in the Glossary.

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Premium The good news is that the price is zero, in most instances. You are eligible for Medicare Part A, premium free, if you have paid income taxes for 40 quarters (called Quarters of Coverage by Social Security and you have been a permanent, legal resident in the United States for five (5) continuous years. If You Don’t Qualify for Premium-Free Medicare Part A There is a situation where you do not qualify for premium-free Medicare Part A.  That is your situation if you and your spouse have not paid Social Security taxes for the required amount of time, which is 40 quarters. The technical term for this is quarters of coverage (QCs). If this is the case, then you can pay for Medicare Part A yourself. It will be costly. In 2017, Part A will cost $422.00/month for those that have worked 0-29 QCs. Part A will cost $232.00/month for those that have worked 30-39 QCs. It is important that you contact your local Social Security administration office in order to confirm your status. You may be subject to a 10% Part A Late Enrollment Penalty, which lasts twice as long as the period in which you did not sign up, but were eligible, if you enroll after the Medicare Initial Election Period (open enrollment period) ends.  How long do you pay this penalty? You pay the penalty for twice as long as the period that you did not enroll. An example would be easier. If you delayed for 3 years, then your penalty would be 10% per year for 3 x 2 = 6 years.

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Part A Benefits Inpatient Hospital Stay Deductible:

$1,340.00 per benefit period

First 60 Days Cost:

You pay $0. Medicare pays.

Days 61-100 Cost:

You pay $335.00 a day.

Days 101-150 Cost:

You pay $670.00 a day.

Days 150+ Cost:

You pay 100%

Skilled Nursing Facility Care Stay First 20 Days Cost:

You pay $0.

Days 21-100 Cost:

You pay the first $167.50 a day.

Days 100+:

You pay 100%

Skilled Nursing Care is a technical term and does not include solely custodial care. Inpatient Psychiatric Care 190 days lifetime benefit, Medicare pays 100% Hospice Care You pay:

$0 for hospice care

A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management 5% of the Medicare-allowed charge for inpatient respite care (short-term care given by another caregiver, so the usual caregiver can rest) Medicare doesn’t cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).

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Blood In most cases, the hospital gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated. Part A Inpatient Hospitalization Deductible The negative is the large deductible associated with Medicare Part A. The largest of these is the deductible that accompanies an inpatient hospital stay. For a hospital stay in 2018, the deductible is $1,340.00. For every benefit period (see Key Term: Benefit Period in the next section), you are obligated to pay the first $1,340.00 of total hospital costs. The table at the end of this chapter shows the schedule of deductibles that you are obligated to pay if you are admitted to a hospital.  The very high deductibles and copayments required under Medicare Part A are the primary reason that being covered solely by original Medicare (Part A and Part B) is a very bad idea, and should be avoided if possible (and it is avoidable).  Any Medicare Advantage or Medigap plan, with prescription drug coverage, will be superior, and potentially save you thousands of dollars, if you are admitted even once to a hospital in any given year. If you or someone you know is in extreme financial distress, then there is governmental assistance available under the LIS (“Limited Income Subsidy”) or the “Extra Help” program, described in the previous chapter. Finally, there are Medicare Advantage plans with no premium, which have all been approved by the CMS. In addition to the high cost of deductibles and copays that accompany Medicare Part A, one other consideration is that the amounts of these deductibles and copays are determined by Medicare.  They are subject to change annually. They are the source of annual debate and speculation.  You don’t need a crystal ball in order to predict which direction these amounts are going over time: up.  It is a very large concern that — 14 —


the Medicare system itself is experiencing extreme fiscal stress; one way to “fix it?” Raise taxes (IRRMA can be rightfully considered a tax increase). Another way?  Raise the cost-sharing responsibility (copays and co-insurance). Given these alternatives, the best solution is to obtain a policy to cover these potential out-of-pocket expenses, within financial resources. In 2018, the inpatient hospital copay has increased from $1,316.00 per stay (in 2018) to $1,340.00 per stay. After 60 days, the daily copay has also increased, as well as the copay required Fin you stay in a skilled nursing facility. Copays In addition to the $1,340.00 deductible for inpatient hospital admission, copays that accompany Medicare Part A are also expensive.   If you need to stay at a hospital for longer than 60 days, the daily amount that you would pay with Medicare Part A will be $335.00.  It gets worse, and can be $670.00 a day between days 101-150. Beyond that, you are responsible for 100% of the daily cost. Key Term: Benefit Period The key term to know about Medicare Part A is “benefit period.”  The Medicare Part A deductible is not an annual deductible.  It is a deductible which exists for each benefit period. In everyday language, a benefit period can best be understood as a medical episode. For example, if you have a right knee joint replacement in January, you may be admitted to a hospital. Then, you will require rehabilitation, which may be done at home, or at a facility.  Six months later, imagine that your other knee requires joint replacement surgery. This is an entirely new benefit period and you will be responsible for another Part A deductible.  Strictly speaking, the benefit period expires 60 calendar days after being discharged from the hospital for that particular medical issue.  If you — 15 —

have a different medical problem that requires hospitalization within that 60 days, or if you are readmitted to the hospital for the same issue after 60 calendar days, then that is another benefit period. You will owe another $1,340.00, and you may repeat this for an unlimited number of times in one calendar year. Now, it may be unlikely that you will have multiple benefit periods in a year. Requiring many separate hospital admissions within one calendar year is pretty bad fortune for a person, to say the least. However, it illustrates the fact that the deductible is not the deductible that you normally presume. If you or someone you know has been admitted to a hospital and has seen an itemized bill can confirm, it is very common that the cost of a single hospital stay will exceed the deductible; that means that you will most likely have to pay the entire deductible amount per hospital admission. Skilled Nursing Facility Care (SNF) One very important point must be made clear: Medicare is not intended to be long-term care. It is not intended for use at a skilled nursing facility for extended periods of time. There are financial policies and contracts which exist to address this, and they are described in Chapter 9. Consider skilled nursing facility care under Medicare. If you review the list at the beginning of this chapter, you can see that the first 20 days at a skilled nursing care facility are paid by Medicare.  Between days 21-100, you will have to pay coinsurance, which is the first $167.50 per day.  Medicare will pay the remainder. This amount is set annually, and may (almost certainly will) increase in the future.  Since most skilled nursing home facilities cost more than $200/day, you will be most likely be required to pay the entire $167.50 per day for days 21-100 of a stay at a skilled nursing care facility. This type of care does not include custodial care, which is the care required for completing tasks such as doing groceries, and cooking. 

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A major change was introduced during November 2012. In the past, you were required to be making progress towards recovery in order to be eligible for Medicare benefits. However, this is no longer the case. You do not have to meet an “improvement standard” to receive skilled nursing care benefits under Medicare Part A. For people who have suffered a stroke, or have been afflicted with Alzheimer’s disease, this is a very welcome change, since the condition may not improve, and yet, a patient may be eligible for Medicare benefits. Observation Status When you are admitted to the hospital, you may or may not know that you can be admitted as inpatient or under observation status. In order to receive Medicare Part A benefits for Skilled Nursing Facility care, two criteria, not just one, must be met: a) inpatient status, and b) the stay must last for at least 3 days (crossing 3 midnights, actually). However, if you are placed under observation status, then original Medicare does not cover the first 20 days in a Skilled Nursing Facility. In that case, the cost of a Skilled Nursing Facility is not covered by Medicare Part A. The cost is covered by Medicare Part B, which is very likely to be much higher, depending on your Medicare configuration. Medicare Advantage, Medigap, or group-sponsored plans may be effective in reducing out-ofpocket expenses. Why the confusion over hospital status? Hospital systems are under pressure to reduce the number of patients that are admitted, and then re-admitted for the same medical reason. Why? The CMS is penalizing hospital systems based on the frequency of hospital admittances. Therefore, hospitals are logically, rationally motivated to admit patients on observation status, not inpatient status. Studies of hospital practices, however, seem to suggest that this practice does not systematically occur. On August 6, 2015, H.R. 876 – NOTICE Act, was passed into law. The law requires hospitals to provide written notice to patients that receive hospital services under observation status for longer than 24 hours. The — 17 —

complete language of the law can be found here online: https://www. Hospital systems must comply with this law by August 6, 2016. This is an important development because patients have not been aware of their status while being treated in a hospital, but this new law makes it mandatory for the hospital to reveal that status, and notify the patient in writing. As of this writing, the law is too new to collect evidence that proves whether this statute has been proven to be effective. In a clever development, certain Medicare Advantage plans cover Skilled Nursing Care, even if not accompanied by a 3-day inpatient hospital stay. There is will be addressed further in Chapter 5. The Two-Midnight Rule The Bipartisan Budget Act (H.R. 1314) formalized the “Two-Midnight Rule.” If you stay at a hospital and receive services (not generally including the emergency room) over 2 midnights, then you are presumed to have been admitted under Inpatient status, not Observation status. This rule takes effect for hospital admissions as of October 1, 2013. The implication of this is that if you believe that you have been billed in error in the past, then you may have the ability to appeal, and have Medicare Part A provide coverage, retroactively. This does not mean that it will occur automatically. While the exact timing of what constitutes when the period begins, from when “2-Midnights” is measured is confusing to say the least, this will be taken as a positive development for Medicare beneficiaries. No Annual Out-of-Pocket Expense Limit The good news is that there is no limit on the lifetime amount of benefits that you can receive under Medicare Part A. The bad news: there is no limit to the amount of out-of-pocket expenses that you can incur under Medicare Part A (or Medicare Part B).

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Table 1. Medicare Part A Cost Sharing (2018) Source: CMS

Hospital First 60 Days Cost: Inpatient stay You pay $0. Days 61-100: You pay the first $335.00 a day. Medicare pays the rest.

Deductible: $1,340.00 per benefit period (See Glossary for definition of benefit period)

Days 101–150: You pay the first $670.00 a day. Medicare pays the rest. Days 150 +: You pay 100% Skilled Nurs- First 20 Days Cost: ing Facility Medicare pays 100% Care Stay Days 21-100: You pay the first $167.50 a day; Medicare pays for the remainder. Days 101+: You pay 100%

Inpatient Psychiatric Care

190 days lifetime benefit, Medicare pays 100% You pay $0.

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ONLY after a 3-day inpatient stay at a hospital Skilled Nursing Care is a technical term and does not include solely custodial care.

NOTES PAGE ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������

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 MEDICARE PART B (MEDICAL INSURANCE) Truths and Myths: Truth: Part B premiums will increase in 2018 for many Medicare beneficiaries due to an increase in Social Security benefits. Truth: The Part B deductible is an annual deductible. Myth: There is an out-of-pocket maximum associated with Medicare Part B. Premium Premiums are indexed to income, which means that if you earn more than $85,000 as an individual, or greater than $170,000 filing jointly, you can be charged more for your Part B. You will be charged according to the schedule in Table 2 at the end of this chapter and online (http:// In many cases, this amount is deducted directly from your Social Security check. This is not a requirement. That is, you can receive a bill for the monthly premium, if you so choose. In some cases, direct bill is the only possible way to pay.  For example, federal employees do not generally receive a Social Security check. In addition, you may have saved money in a tax-advantaged savings account. A little-known fact is that funds in an HSA (Health Savings Account) can be used to pay for your Medicare Part B premium.  

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Annual Deductible In addition to the monthly premium, there is an annual deductible, known as the Part B deductible. For 2018, this amount is $183.00 per calendar year. You are obligated to pay the first $183.00 for medical services received.  Due to the Patient Protection and Affordable Care Act (PPACA), a fee cannot be charged to you for your annual preventive care checkup. In other words, the preventative care screening is complimentary and you should not be charged. There are a few important points here to keep in mind. First, all services you receive must be deemed to be reasonable and necessary by the medical provider. Medicare, and Medigap (but not necessarily Medicare Advantage), will require this before paying any benefits.  Hint: before receiving a diagnostic exam or therapy, simply ask the provider if that exam or therapy is medically necessary.  A confident, competent medical professional should not be offended by this question. If a medical professional becomes defensive when asked this, then you need to ask yourself some serious questions.  Second, the $183.00 is based on Medicare’s allowed charges, a concept discussed later in this chapter.  So, if a service received has an allowed charge of $100.00, and the doctor charges you $115.00, only $100.00 counts towards the deductible.  Third, the deductible is defined by the Medicare on an annual basis. All details (premiums, copays, and coinsurance) under Medicare are changed by the government every year.  That means that it can move up or down every year.  That is a consistent theme of this book; the Medicare system can change, and it is most likely to change for the worse in the long run, even if stable in the short run.  Before it does, you should use the options at your disposal to secure your healthcare coverage, while you are able to do so. Once limits are imposed by the Medicare system, then these options may not be available. 

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Once you have paid the $183.00 annual deductible, then you have the coinsurance arrangement with the Medicare system. The Medicare system will pay for 80% of approved, medically necessary services. You will be obligated to pay for the remaining 20%. If you require surgery, and the physician charges $30,000, then you will owe at least $6,000.  Hold on a second. Could you owe more than $6,000, when that is 20% of the total cost? Yes. You can owe more than this.  It is very important to understand what this 80% and 20% means. Medicare will pay 80% of the Medicare-allowed charge. What is the Medicare-allowed charge?  Key Term: Medicare-Allowed Charge Medicare has a long list and extensive, almost exhaustive, list of services and treatments delivered by doctors or medical professionals. Each item has an amount which it will pay to medical providers for that particular service. That is the Medicare-allowed charge. Presuming that the service is deemed reasonable and necessary, Medicare will pay 80% of the allowed charge, leaving you with 20% as an out-of-pocket expense.  Confusion often occurs when the doctor/medical provider charges more than the Medicare-allowed charge.  A medical provider can bill up to 15% more than the Medicare-allowed charge. When this the case, then a number of different scenarios can occur.  First, the doctor may accept the Medicare-allowed charge as full payment.  You will simply owe the 20% of the Medicare-allowed charge.  However, the medical provider may not accept the Medicare-allowed charge as full payment. So, in addition to the 20% of the Medicare-allowed charge that the Medicare system does not pay (which you will have to pay), you will also have to pay the entire extra amount that the medical provider charges above and beyond the Medicare-allowed charge.  The amount above the Medicare-allowed charge is called the Medicare Part B Excess. Confused?  Let’s try an example to illustrate this important

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concept. It is important because then you can make a better-informed decision to Maximize Your Medicare. This section intentionally left blank.

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Part B Excess Example This Happens. A doctor wants to charge $30,000 for some procedure and the Medicare-allowed charge is $27,000.  In addition, Let’s presume that you have already satisfied the $183.00 annual Part B deductible.  In this case, the doctor can choose to take the $27,000 and accept that as full payment.  In this case, the physician has accepted the Medicare “allowed charge.”  However, the doctor can also send you the entire bill. What will happen is Medicare will pay for 80% of $27,000 (which 80% x $27,000 = $21,600), and you will have to pay $5,400 (=20% of $27,000). In addition, you will need to pay the entire amount that the doctor charges above the Medicare “allowed charge” amount.  In this example, that is $3,000 ($30,000 less $27,000).  Therefore, your out-of-pocket expenses would be $5,400 + $3,000 = $8,400. Total Bill = $30,000.

Medicare-allowed charge= $27,000. Medicare Pays = $27,000 x 80% = $21,600, NOT $30,000 x 80%. You Pay 20% of Medicare-allowed charge: $27,000 - $21,600 = $5,400. You Pay the Entire Part B Excess Charge = $30,000 - $27,000 = $3,000. Your Total Cost = $5,400 + $3,000 = $8,400. This Happens. The fact is that the surgeon is entitled to charge this amount within the existing rules of Medicare.  There is an important exception to this: certain states have laws that prohibit a medical provider from charging more than — 25 —

the Medicare-allowed amount. These states are Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island and Vermont. The law that prevents Medicare Part B excess charges is called the Medicare Overage Measure Law (MOM). If you think that you can simply move to one of these states in order to avoid this, then understand that anecdotal evidence strongly suggests that the Medicare-allowed charges in these locations is higher, and therefore, premiums are also higher for Medicare Advantage and Medigap plans. If you do not live in one of these states, and you have to pay for the Medicare Part B Excess even once in your lifetime on this type of procedure, it is likely that the extra premium paid would have more than paid for this cost by a very wide margin. It is important to note that under almost every group plan, employer-provided plan, as well as under every Medicare Advantage (MA) plan (including MAPD), the Part B Excess is not covered. On the other hand, certain Medicare Advantage plans disallow “balance billing,” which is charging the patient an amount above the amount paid by the Medicare Advantage provider to the healthcare provider. While the probability may be small, the potential financial effect can be dramatic. You need to carefully consider this point when deciding on the proper coverage under Medicare.  The benefit of having this paid, without worry, may be worth the extra cost. This is particularly true for those that have known medical issues when entering the Medicare Initial Enrollment Period.  Under the existing Medicare system, only Medigap Plan F, High-Deductible Plan F, and Plan G cover the Part B Excess.  In addition, one type of MA, called PFFS, can result in no Part B Excess, because the medical provider has agreed, in advance, to accept the Medicare-approved amount as full payment. Cancelling Medicare Part B Cancelling Medicare Part B is a serious matter, but you can do it. For example, you may return to full-time work at an employer whose bene— 26 —


fits plan does not require enrollment in Medicare Part B. You will need to go to your local Social Security Administration office itself, and go through an interview. That will allow you to fill in a form named CMS1763. The SSA will not mail you one, and it is not available online. The reason is that if you attempt to re-enroll, then you may be required to pay a penalty. Then again, if you are canceling Medicare Part B to enter into another plan which is deemed to be creditable coverage, then you can re-enter Medicare Part B without penalty. The SSA wants to make sure that you understand the consequences. This is complicated, and needs to be handled carefully. PPACA (“Obamacare”) and Medicare Part B In addition to the “Welcome to Medicare” preventative care visit, a provision of the PPACA is that every person with health insurance is allowed an annual wellness visit, free of charge. Specific screenings, particularly for those people that are deemed to be in a high-risk category, are also included. The language and specifics of this are very subject to change and the individual situation: please check with your medical provider and check your bill carefully to verify that you have not been billed if you believe that you fall within this criteria. No Maximum Out-of-Pocket Expense Limit The good news is that there is no limit on the lifetime amount of benefits that you can receive under Medicare Part A or Part B. The bad news: there is no annual limit to the amount of out-of-pocket expenses that you can incur under Medicare Part A or Medicare Part B. This has very powerful implications to financial planning and retirement planning. The notion that “I have my Medicare card, I’m all set” is not correct because your financial liability, if you face a medical situation that persists: unlimited. Thinking that Part A, Part B, and Part D alone are sufficient cannot, therefore, be correct, especially when you consider that some Medicare Advantage plans (Chapter 5) can cost no additional premium, and include an annual out-of-pocket limit. — 27 —

Table 2. Medicare Part B Premium (2018) Source: CMS Individual $85,000 or less $85,001 - $107,000 $107,001 - $160,000 $160,001 - $214,000 Greater than $214,000

Joint $170,000 or less $170,001 - $214,000 $214,001 - $400,000 $400,000 - $428,000 Greater than $428,000

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Monthly Premium $134.00 $187.50 $267.90 $348.30 $428.60


 MEDICARE PART D (PRESCRIPTIONS) Truths and Myths Truth: Checking your Part D plan can save you money. Not checking your Part D plan can cost you dearly. Truth: Premiums, deductibles, copays and approved drug lists change in every plan, every year. Myth: You can have multiple prescription drug plans. Truth: The exception is that both VA prescription drug benefits and a separate Part D plan, or a Medicare Advantage plan that includes prescription drug benefits is allowed. Stand-alone prescription drug plans (PDPs) are also known as Medicare Part D. Sometimes, the terminology can be confusing. For those enrolled in an MAPD plan, a separate Part D plan is unnecessary. In most instances, the Medicare system will not allow you to have multiple prescription plans that fit the “creditable coverage” standard.   Enrollment For those that are newly eligible for Medicare Part A and Part B, the Medicare Initial Enrollment Period applies. In our “Jane Doe” case, she turns 65 on February 13, 2013.  That means she can enroll in Part D plans as early as November 1, 2012, and as late as May 31, 2013, without incurring a penalty. — 29 —

Part D Late Enrollment Penalty After May 31, 2013, “Jane Doe” will begin to incur a penalty if she has not enrolled in Medicare Part D. The Medicare Part D penalty rate is 1% for every month that you do not enroll. The amount of the penalty is based on the national average of the price of a prescription drug plan, not on the 1% of the plan that you select.  Additionally, the penalty never expires.  Let’s start with an example. Say you choose an inexpensive prescription drug plan. The penalty will not be based on your plan’s premium.  So if the average drug plan costs $35.02, the 2018 average, then your penalty would be $0.3502 for every month that you did not enroll in the plan during your open enrollment. If you are required to pay a penalty because you delayed enrollment for 10 months, then you will be required to pay a 10 x $.3502 =$3.502 monthly penalty. This penalty will never expire. Important note: the maximum penalty would be calculated from June 1, 2006. If you are required to pay a 15-month penalty, the calculation is 15 x $0.3502 = $5.253, rounded to $5.30 (the nearest 10 cents). It gets worse because every year the penalty is recalculated, so if next year, the average drug plan is then $38.00, then the penalty will be 27 months (a year has passed) x $0.38 = $10.26, in addition to the Part D plan premium. Premiums

Premiums are indexed to income, which means that if you earn more than $85,000 as an individual, or greater than $170,000 filing jointly, you can be charged more for your Part D. The additional amount is called the Income-Related Monthly Adjustment Amount (IRMAA). The IRMAA will automatically be deducted from your Social Security benefit. Complete details on the amount are found in Table 3 at the end of this chapter.

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Here are the terms of Medicare Part D (premiums NOT included): $0-$405: If the costs are between $0 and $405 in a calendar year, then the Medicare Part D is paid according to the plan that you purchase. Premiums, deductibles, and copays vary by plan. Applicants should check on the website  in order to find out which Medicare Part D plans cover the drugs that the applicant takes. $400-$3,750:  You pay a co-pay of the total costs of prescriptions between $400 and $3,700. The Medicare Part D pays the remainder. $3,750-$5,000:  In 2018, there is a 60.0% discount on covered brandname prescription drugs and a 49% discount on the cost of generic drugs while in this gap. This is called the Coverage Gap by the CMS, and is commonly referred to as the “donut hole.” The important thing here is that certain stand-alone prescription plans provide for partial coverage inside the Coverage Gap (described later in this chapter). If this is you, and you know in advance that you will fall within the Coverage Gap, then it can be the case that you should choose a plan with a higher premium, which may result in lower overall costs throughout a calendar year. You should actively check this every year. $5,000+:  You pay the maximum of $3.30 or 5% of the total costs of generic and multi-source preferred prescriptions above $5,000.  For preferred prescriptions, you will pay the maximum of 5% or $8.25. The Medicare Part D provider pays the remainder. This is called catastrophic coverage. Why People Misunderstand the Coverage Gap It is entirely understandable that people find the Part D coverage gap confusing. The primary reason is that the numbers in the prior section are not your actual amounts paid, but the sum of the retail cost of your medications. Let’s take Levothyroxine Sodium, the generic form of Synthroid, used to treat hypothyroidism. Let’s presume that you have a standalone prescrip-

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tion plan named “Acme Medicare PDP.” Acme has negotiated a price, for example, $30 for a 90-day supply. Let’s say that your copay, under the Acme Medicare PDP, for Levothyroxine Sodium is $15 for the 90-day supply. In this case, $30 is to calculate where you stand with respect to the Coverage Gap. In addition, the monthly premium that you pay for your Acme Medicare PDP is not included in the calculation. Choosing the Right Plan

Once you have decided to enroll in a prescription drug plan then the question is what the best plan for you. This will require some work on your part. You may request the assistance of an agent.  You can do it yourself by going to  Here are the steps to take: 1. Click “Find health & drug plans.” 2. Enter your zip code. 

3. Choose the “I don’t know what coverage I have” selection, and choose the “I don’t know” selection. Click on the “Continue to Plan Results.”  4. You will be sent to Step 2 of 4: Enter Your Drugs page.  Follow directions.  Enter the drugs and the dosages that you require.  Once completed, click “My Drug List is Complete.”  5. You will be sent to Step 3 of 4: Select Your Pharmacies.  Choose pharmacies from the list.  When complete, click “Continue to Plan Results.” 6. There will be three categories.  The one to choose is the FIRST ONE, called “Prescription Drug Plans (with original Medicare).”  7. The results will come out under “Prescription Drug Plans.”  The results will be in order; the least expensive plans are listed first. Very important note: you can sort by Lowest Estimated Annual Mail Order Costs, in addition to Lowest Estimated Annual Retail Costs. The answers can be different, do not presume that the order will be the same. In fact,

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it is very likely that the order changes when you sort differently. It is important to remember that the results are estimates only. Helpful hint: You do not need to do this more than once. Write down the Drug List ID and Password Date listed near the top of the website. It can be used again to recall the list of prescriptions that you have input into the site.  Guidelines for Choosing the Right Part D Plan Here are some general concepts to understand regarding stand-along prescription drug plans (PDPs).  Some prescription drug plans will require the beneficiary to pay the annual deductible.  Some will not. Your medication may or may not be covered. That will result in higher outof-pocket costs, but every plan must cover at least two medications per medical condition. If your drug is not covered by your plan, there can be exceptions. This can occur when your doctor writes a letter to essentially appeal your case.    Copays. Different copayments will exist for each drug, and it will not be the same across plans. That is why you may need the assistance of the website or an insurance agent. Paper copies of the formularies that itemize the medications covered by your MAPD plans are sent before the Annual Election Period to enrollees. Formulary. Each plan will have a formulary, a list of medications covered by the plan, and the “tier” which specifies your financial responsibility. It can be tricky, since the formularies (list of approved medications) can change within a calendar year. Every formulary will have at least two medications for each medical condition, as governed by the CMS. Prior Authorization & Quantity Limits. Certain medications create financial complications due to their high cost. Your plan may require Prior Authorization or may impose Quantity Limits. Your physician can provide a written explanation to grant Prior Authorization or to override Quantity Limits. In addition, those with expensive medications need to work with insurance companies because the insurance companies may

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expect you to participate in a therapy program to make sure that you are not taking an unnecessarily-expensive medication for an extended period. If you do not have access to the internet, then you can ask an insurance agent or broker to do this for you. If he/she can’t or won’t, then here is a piece of advice: find another agent who will.  Preferred Pharmacies and Mail Order Prescription plans often use preferred pharmacies and mail order: they should be used whenever possible. When you select a stand-alone prescription drug plan, it is important to input those pharmacies that you frequently use. Then, and only then, will you receive an accurate list of the cheapest plans. The same can be said for mail order. This Happens.  Mr. B has one expensive medication, and a few generic medications. The expensive medication has a much lower copay at one specific pharmacy, when compared to other pharmacies. Even though the plan has a deductible which is twice the cost of other competing plans, the overall anticipated drug costs is much lower. The difference between the first and second most efficient Part D plans? $1000 a year. This Happens.  2018 Update: the combination of preferred pharmacies and formularies has made 2018 the most complicated year in recent memory. The average plan in 2018 has a lower monthly premium. The difference in total prescription drug expenses will vary widely, based on the specific pharmacies that a person prefers. If the pharmacy is not a preferred pharmacy, then the total prescription cost can be much higher under that plan. — 34 —


Part D plans have a mail order option for many prescriptions, and these can reduce out-of-pocket expenses dramatically. That said, some people are not comfortable in receiving prescriptions via mail. Certain medications have a very high “street value,” especially in the case of pain management medications, and special care must be taken in delivery of these sensitive drugs. Changing Plans You can change your Part D plan during every Annual Election Period (AEP) without restriction. That means that if your prescriptions change during the year, the best plan may also change. This is important to keep in mind. Even if your prescriptions do not change throughout the year, you should still check to confirm that your plan is the best for you. The reason? Premiums will change, copays will change, prescription coverage will change for different plans on an annual basis. This means that the plan that fits you best may also change. It may be costly to not check. The Coverage Gap (“Donut Hole”) and You The Coverage Gap is commonly referred to as the “Donut Hole.”  It is described above in the description of Part D plans. Frankly, it receives more attention than it deserves, because the vast majority of people will take generic medications whenever possible, and the result is that the donut hole will not be a factor. However, “donut hole” is a snappy piece of jargon which is useful at the coffee shop amongst friends. That all said, here are the situations that describe the vast majority of Medicare-eligible. The donut hole is irrelevant if the total drug costs are less than $3,750 during the calendar year.  Remember that total drug costs is the sum of retail drug costs, not your total deductible and copays. You will follow your Part D plan. Be sure to read the Money-Saving tips at the end of this chapter.

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However, when the total drug costs reach $3,750, then you enter the donut hole. For 2018, your prescription drug plan converts to a fixed schedule where you have to pay 35.0%, at most, for non-generic drugs, 44.0% of the cost for generic drugs. This continues until your copays/ coinsurance amounts total $5,000. When your total drug costs have reached $5,000, catastrophic coverage begins, and the price is 5% of the cost for non-generic medications. That is obviously a great deal of money, and it starts all over again every calendar year.  Certain plans have partial Coverage Gap protection. It should not be surprising that those with partial Coverage Gap benefits usually are accompanied by higher monthly premiums than those plans without Coverage Gap benefits. The important thing is to not simply choose a plan based on its lower premium; that may result in higher prescription costs over an entire year due to higher copays. Important point: for those who receive prescription coverage from other sources, it may be reason to stay with a group plan or retiree group coverage. Please see the next section called “Employer Group Plans and the Coverage Gap (‘Donut Hole’),” where this complicated matter is addressed. Employer Group Plans and the Coverage Gap (“Donut Hole”) An entire chapter is devoted to employer-sponsored group plans for Medicare-eligible employees and retirees.  Nothing here is inconsistent with that section, and if you have an employer-sponsored group plan, then you should refer to that chapter.  The important question about the donut hole is how it may be better or worse than your existing prescription plan. In certain employer plans, there is no concept of donut hole. That means that if your drug costs are very high and you compare your estimate of annual costs under Medicare Part D to how much you would pay through your employer plan, the drug portion may be cheaper in your employer-provided group plan than it would be — 36 —


under a stand-alone Part D (prescription drug plan). As a result, you may want to stay with your employer plan. However, it isn’t always that simple. Sometimes people say “I want to stay with my employer due to the fact that the drug cost will be lower.” This may be true, or not. At the risk of being repetitive: do not assume that the best case is staying with your employer-provided plan. It is financial reality that you, as a retiree, are not the priority, when compared to global competition and the need to satisfy active employees. If you conclude that this is the case, after asking the right questions, then it is fine for you to stay with your retiree plan. Not before examining the facts. Even if there is no donut hole, it may not be entirely clear that this is reason enough to stay with an employer group plan. Your prescription savings need to be compared to the savings that you might have gotten on superior medical plans in the private market as a whole. Remember: medical coverage in the private market is frequently superior to the coverage in a group plan. Therefore, your employer-provided medical benefits must be weighed against the medical plan that you would have under an MA or a Medigap plan. On balance, the medical coverage and cost sharing arrangement under an MAPD or Medigap plan may be worth the extra cost. That has to be done on a case-by-case basis and there is no shortcut to it.  An advisor or an agent may be useful in this case because he/she would be able to add up the plan’s costs, as well as their benefits, for you, so that you choose the best overall plan. It is vital that Medicare-eligible persons understand that the two components (medical and prescription) be considered in combination, and not one without regard to the other. The reason that is important to consider both the prescription plan as well as your medical plan together is that if you are concerned about the high cost of prescriptions, then it is usually the case that you have a medical situation which requires constant attention. One common mistake is that people ignore the correlation between prescription costs and the medical services they require. The reason that people — 37 —

get rejected by private insurance companies before becoming Medicare-eligible is that insurance companies do not make this mistake. Insurance companies know, given a list of medications, that further medical services will be required in the future if a person takes multiple medications. Extra Help Program “Extra Help” is a program sponsored by the federal government. It has been as the Limited Income Subsidy (LIS) in the past. If you qualify, then the Extra Help program can pay a portion of your Medicare prescription drug costs. The Extra Help program may pay all or part of your monthly Medicare Part D plan premiums and a significant portion of your medication costs. You can apply for the Extra Help program online at, you can call Social Security at 1-800-772-1213, and you can apply at your local Social Security office. If you receive Extra Help, then you will also pay either a low or no initial deductible and will not be subject to the Coverage Gap (“donut hole”) of Medicare Part D as described in Chapter 5. You do not have the same restriction as others if you qualify for the Extra Help program, i.e. you can change plans at any time during the year, without restriction. Put another way, if you qualify for the Extra Help program, then your entire year is an SEP. If you qualify for the Extra Help program, then you need to be aware that there a number of different levels of assistance. In addition, you need to check the letters (don’t discard them!) that you receive in order to understand your individual level of assistance, which is subject to change, every year. Every year, you may receive a letter from Social Security Administration, which will update you on your status.  You may be told that you do not qualify for the next year. If this is the case, then this is one type of Special Election Period (SEP), and you will be able to adjust your selection of Part D, as well as enroll in an MA plan, or a Medigap plan. You may — 38 —


receive a letter requesting additional information; this is a very important letter (which is one reason to never throw away letters from the CMS), because if you do not answer the letter, then you can lose your access to the Extra Help program entirely. Money-Saving Tip #1 and 2018 Update Many people choose a stand-alone prescription drug plan (Medicare Part D), and then, simply due to convenience, a Medicare beneficiary simply chooses to stay with the same plan. Given the other advice contained in this book, you can anticipate the reaction to this: bad idea. It would be better to check your annual costs using the steps listed in “Choosing the Right Plan” every year. The reason is that not changing can cost, on average, 10% a year on your premiums. That is the conclusion of the study conducted by Keith M. Marzilli Ericson in a working paper, published in September 2012, of the National Bureau of Economic Research (NBER), the nation’s foremost collection of economists.  Bottom line: check your list of prescriptions annually, and use the directions as listed in “Choosing the Right Plan” every year. Even in cases when your prescriptions stay the same, the cost sharing arrangement can change for the same plan from year to year. That can also result in much larger overall prescription drug costs. For example, instead of a percentage there may be a copay schedule; some very large, popular Part D plans are changing away from a fixed dollar amount. If you have a non-generic medication that costs $20/month under a copay schedule, you will need to check your new 2018 schedule. You have to pay 25%, or $40 a month, this year your plan, if your plan has switched to at 25% coinsurance schedule. In this case, it will cost $240 more under this type of cost-sharing arrangement. While the premium understandably dominates the attention, it does not tell the whole story.

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Money-Saving Tip #2: Check Pharmacies Carefully Choosing Part D plans has become increasingly difficult. The financial results vary dramatically, depending on the plan you choose. This has been true in the past, and it is becoming more extreme over time. Anecdotal evidence has proven 2018 to be a very extreme year. It used to be the case that a few plans dominated most locations. However, the results vary more wildly, depending on the prescriptions one is prescribed, the “tier” of each medication, the method of delivery (mail-order or retail), and pharmacies. Let’s take an example. Take Latanoprost, which are eyedrops used to treat glaucoma. For those that do not know, prescriptions that are “drops,” or “creams” are generally expensive, and different plans handle these prescriptions very differently. Take Prescription Drug Plan #1. This plan may charge a higher premium, but with no deductible. If this occurs, Latanoprost may not be subject to the high copay which would occur if there was a deductible. Further, pharmacy A may have negotiated a far different price from pharmacy B. The net result is that the most efficient plan for a person that is prescribed Latanoprost will result in a multiple hundred dollar a year difference between the first and second most efficient plan that available in a particular location. For people that take the most common generics, the total costs may be the same, assuming that your prescriptions do not change throughout the year. However, what happens if you are prescribed a more expensive medication? Then, on average, the higher priced plan, with no deductible, will result in lower overall costs because the copay structure of higher-premium plans is usually, but not always, superior. You will need to confirm that (and all other facts stated in this book), but it illustrates the point that the lowest monthly premium plan may not be the best choice.

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Table 3. Medicare Part D Premiums (2018) Individual


Monthly Premium

$85,000 or less

$170,000 or less

Plan Premium

$85,001 - $107,000

$170,001 - $214,000

$13.00 + Plan Premium

$107,001 - $133,500 $214,001 - $267,000

$33.60 + Plan Premium

$133,501 - $160,000 $267,001 - $320,000

$54.20 + Plan Premium

Greater than $160,000

Greater than $320,000 $74.80 + Plan Premium

Additional amounts ($13.00, $33.60, $54.20, $74.80) will automatically deducted from your Social Security benefits (if applicable). Source: CMS

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NOTES PAGE ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������


 MEDICARE PART C (MEDICARE ADVANTAGE) Truths and Myths Truth: The premiums, deductibles and copays change every year, so the cheapest overall plan can also change. Truth: Networks must be carefully examined in advance to minimize overall costs. Myth: Medicare Advantage is always worse than Medigap. Factually not true. Medicare Advantage plans may include important extra benefits (example: chiropractic services). Let’s turn attention to Medicare Part C, more commonly known as Medicare Advantage. It actually replaces your red, white, and blue Medicare card. That said, you still need to pay the Medicare Part B monthly premium of $104.90 (or $121.80 for new enrollees), unless you receive governmental assistance towards the premium.  A Medicare Advantage plan must cover at least what original Medicare covers, on average (more on this later). There are many different types of Medicare Advantage (also known as MA) plans. Medicare Advantage plans that include prescription drug benefits are frequently referred to as MAPD (Medicare Advantage Prescription Drug) plans. You have received, or you will receive many, many advertisements via mail regarding MA plans. You can also see the available plans in your area on the official Medicare website.

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Enrollment Medicare Advantage Initial Enrollment The Medicare Advantage Initial Coverage Election Period (ICEP) is specific to Medicare Advantage plans. The ICEP is not necessarily the same as the Medicare Part B or Medicare Part D Initial Enrollment Period (IEP). Under the ICEP, the first date that you can enroll for a Medicare Advantage is the same as if you are enrolling in Medicare Part B. However, the last date of the ICEP can differ, and that is the source of confusion. It is a bit convoluted, and can probably be made clear through an example. Let’s go back to Jane Doe, born on February 13, 1948. Case 1. Turning 65 years old and not working. In this example, November 1, 2012 is the first date she can enroll in MA/MAPD and the last date that she can enroll is May 31, 2013, then is the end of Jane’s ICEP. This is the same day she could enroll in Medicare Part B or Part D alone. It is important that these are the same ONLY when turning 65 years old. Case 2. Retiring after 65. If Jane Doe was a full-time employee, with health and prescription drug benefits that qualified as creditable coverage, until July 30, 2015, and her Part B effective date is August 1, 2015. Her Medicare Advantage Initial Coverage Election Period (ICEP) would end on July 31, 2015. The bottom line: if you are considering a Medicare Advantage plan during the time that you become initially eligible for Medicare Part A and Part B, then you can (and should) enroll in Part B, and select any Medicare Advantage plan that includes prescription benefits, as soon as possible. Why? You preserve the flexibility to change among plans during your 12-Month Trial Period (a specific Special Election Period). That will preserve the maximum number of options for you, because you can change your mind, upon further examination of Medicare Advantage plans, and select a different Medicare Advantage plan (within the first 12 months), or select a Medigap policy.

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In addition, you will also eliminate any potential penalties. If you do not qualify for a SEP, and you only sign up for Medicare Part A and Part B, without also selecting a Medicare Advantage plan that includes prescription drug benefits, then you will be subject to the Part D penalty as described later in Chapter 5. You can avoid this entirely by selecting a Medicare Advantage plan that includes prescription drug benefits. Candidly, this is quite a mess, due to the fact that the same terminology (Initial Coverage Election Period, ICEP) is used for both Case 1 and Case 2. The way to resolve this is to enroll in Part B before your first eligibility date, and if you are considering a Medicare Advantage plan, choose one before your Part B eligibility date. Selecting a Medicare Advantage plan that includes prescription drug benefits will allow you to a) change plans within the 12-month trial period without penalty, b) allow you to avoid late enrollment penalties, and c) allow you to cancel within the 12-month trial period and return to original Medicare, with the ability to select a Medigap policy, if you choose. It is very important to note that this 12-month trial period (called “Trial Right”) can only be used if it coincides within 12 months of enrolling in Medicare Part B. Medicare Advantage Annual Election Period When you are older than 65, enrolling in an MA or an MAPD plan is fairly straightforward. You can enroll in a Medicare Advantage plan during the Annual Election Period (AEP). That occurs every year during the fourth quarter.  In 2018, the AEP runs from October 15 through December 7, a period of seven weeks. During the Annual Election Period, will be able to freely change your mind, as many times as you would like. You can change your mind an infinite number of times, and the last plan that you elect will be the plan that is in effect on the following January 1. Since there is no restriction to the number of times that you can change your mind, it may be reasonable to choose the first plan so that you don’t forget, and then you can go and shop around for different plans to the extent that you find the one that — 45 —

is superior to your initial selection. You may have misgivings about this, but the practical reality is that the Medicare system does the cancelling for you. Medicare Advantage 12-Month Trial Right

If you enroll in a Medicare Advantage plan before the date that you are first eligible for Medicare Part A and Part B, then you can cancel at any time during your first twelve months under that plan, and return to original Medicare. It is important to note that this must also be within the first 12 months of being eligible for Part B, if your Part A and Part B dates are not the same. You can then enroll in a Medigap plan (along with a standalone prescription plan, Medicare Part D), or simply stay with original Medicare.  Note: Sometimes even insurance companies mishandle this situation, and do not process this as a Special Election Period under the twelvemonth trial period. Medicare Advantage Disenrollment Period You can disenroll without restriction between January 1 and February 14, every year. Now, here are the important things to keep in mind before disenrolling from a Medicare Advantage plan. First, you would have to independently enroll in a stand-alone prescription drug plan (Medicare Part D), or face penalties. You will be able to select a Part D plan using the Special Election Period. In addition, you can also enroll in a Medigap plan, subject to medical underwriting. Second, it is probably best to wait until you are accepted by a Medigap carrier, before you exercise the right to cancel your Medicare Advantage plan, because if your application for Medigap is refused, then you would be responsible for the copays and deductibles under Medicare Part A and Part B. Special Election Periods (SEP) The Medicare system allows people that have special situations to be able to elect a Medicare Advantage plan outside the Annual Election Period. — 46 —


Here is a list of 12 of them. Moving:  If you have moved, and your previous plan isn’t offered in your new location, OR if you have moved and the new plan wasn’t available in your old location, then you qualify.  If you move from outside the U.S., where you were living permanently, then you qualify. Medicaid Status Change:  If your Medicaid status changes, then you qualify. Limited Income Subsidy (“Extra Help”):  If you are eligible for the Limited Income Subsidy, then you can change without restriction at any time during the calendar year. Skilled Nursing Facility Care:  If you are moving in OR out of a skilled nursing care facility, then you qualify.  PACE (Program of All-Inclusive Care for the Elderly):  If you leave a PACE program, then you qualify.  Note:  PACE is only available in selected states. Loss of Creditable Coverage:  If your prescription drug benefits are ruled to no longer be creditable coverage, then you qualify.  Note: “creditable coverage” is defined in the Glossary. Employer-sponsored Plan Change:  If you are losing your coverage from an employer-sponsored benefit plan, then you qualify.   Pharmacy assistance program:  If you are either entering a Qualified State Pharmaceutical Assistance Program (SPAP), or if you have lost your eligibility, then you qualify. Other prescription drug assistance:  If you no longer qualify for other prescription drug assistance that you have been receiving, then you qualify for an SEP. Medicare Advantage Plan Cancellation:  If your MA plan is no longer in existence, then you qualify (you must elect this SEP only between December 8 and the end of February of the following year).

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Medicare Annual Disenrollment: Between January 1 and February 14, you can cancel, and return to original Medicare and enroll in a standalone prescription drug plan (Medicare Part D).  If you have a PFFS, then you must obtain written permission. Five Star Plan: If you want to switch to an MA plan that is rated as “five star” by the CMS, then you qualify, without calendar restriction. You can switch to a five star plan once, and only once, during a calendar year. Special Circumstances: There can be special circumstances which occur, and the CMS may grant a limited Special Enrollment Period. A prime example is that the CMS extended the Annual Election Period through the end of 2017, for those affected by the severe weather and disruption caused by the hurricanes in the southeast portion of the U.S. In this instance, evidence will need to be provided that you qualify. A general rule of thumb: If you qualify for an SEP, then you have 2 months from the date that you begin an SEP to adopt a new plan, whether that is another Medicare Advantage plan, or a new Medicare Part D plan, regardless of the reasons listed here. Types of Medicare Advantage Plans There are a dizzying number of different types of Medicare Advantage plans.  Frequently, the same insurance company will offer clients multiple options.  Please know that this book will refer to the entire set as Medicare Advantage or MA.  This includes plans in which prescription drug coverage is included, known as Medicare Advantage Prescription Drug plans (MAPD).  Here are the different types of Medicare Advantage plans: • HMO (Health Maintenance Organization) • PPO (Preferred Provider Organization) • PFFS (Private Fee-for-Service) • POS (Point of Service) • HMO-SNP (Special Needs Plan) — 48 —


Each type of Medicare Advantage will differ slightly, and each has some distinctive characteristics. Health Maintenance Organization (HMO): You will need to specify a Primary Care Physician (PCP), who will refer you to specialists as necessary.  All providers must be in the network.  If you obtain routine medical care from out-of-network medical providers, the HMO may not pay any benefits, and you will be responsible for the entire cost. HMOs can be offered with and without prescription drug benefits.  In some states, there is a partial rebate of the Medicare Part B premium that accompanies your participation in certain HMOs. Preferred Provider Organization (PPO):  You do not need to select a Primary Care Physician.  You can seek medical services from providers outside the network, but with a different, higher cost sharing arrangement.  Generally, the number of medical providers that accept a PPO is greater than the number that accepts an HMO (of the same insurance company).  Prescription drug benefits are frequently included in these plans. Private Fee-for-Service (PFFS):  You can use a medical provider of your choice, but that provider must accept Medicare assignment of benefits, which means that it must accept Medicare’s allowed charge as full payment.  As a result, there is no possibility of Part B Excess Charge under this plan.  However, a provider has the choice to accept you on a case-bycase basis, except in emergencies.  This means that if you go to a doctor for one illness, and you are accepted, that does not guarantee that the same doctor must accept you the next time you attempt to receive services from that medical provider.  PFFS plans may, or may not, include prescription drug benefits.  PFFS is the only Medicare Advantage plan in which you can purchase a separate, stand-alone prescription drug plan (Part D).  Lastly, if you attempt to cancel your PFFS by using a Special Election Period (SEP), you must request permission in order to do so. Point of Service (POS):  You will need to specify a Primary Care Physician (PCP), who will refer you to specialists as necessary.  If you seek medical attention from those inside the network, then your PCP will coordinate benefits and administer the cost-sharing terms as a courtesy to — 49 —

you. In certain circumstances, an HMO-POS plan will allow you to seek treatment from a provider that is outside the network. HMO-SNP (Special Needs Plan):  There are three general types of HMOSNPs. The first is when you have a chronic illness. The second is when you are resident in a skilled nursing facility. The third is when you qualify for both Medicare and Medicaid (otherwise known as Dual-Eligible SNP or D-SNP). You must qualify to enroll in these plans.  You will need to select a primary care physician (PCP), and depending on the SNP, there will be specific types of formularies for your particular chronic illness, if that is the basis of acceptance to the HMO-SNP. Under a D-SNP, you will almost certainly need to have a case worker assigned to you by the Department of Health and Human Services and the Social Security Administration. In addition, an insurance company will most likely appoint its own individual assistant in order to coordinate benefits.  The level of assistance granted is extremely complicated, and depends on your net worth and income.  All medical services must be administered by providers in the HMO’s network.  If you receive services from a non-network provider, then you must pay the entire bill.  Medicare will not pay and your HMO-SNP will also not pay. Medicare Advantage Prescription Drug Plans (MAPD) Medicare Advantage Prescription Drug Plans combine health insurance with prescription drug coverage in one plan.  Some of the different types of Medicare Advantage plans listed in the previous section can also be an MAPD.  For example, a Medicare Advantage plan, which is also an HMO, may or may not include prescription coverage.  Important fact:  If you have an MA or an MAPD plan, you cannot have a separate, additional stand-alone Prescription Drug Plan (Part D). The exception to this is PFFS, in which case you can have a separate PDP, or in certain cases, prescription drug benefits are embedded in the PFFS plan itself. If you elect a Medicare Advantage that does not include pre— 50 —


scription benefits that is ruled as creditable coverage by the Medicare system, then you will have to pay for prescriptions entirely from your own funds. In addition to this, you will be subject to the enrollment penalty at the time that you do enroll in a stand-alone Medicare Part D (prescription drug plan), or a Medicare Advantage plan that does include prescription benefits. Premiums Medicare Advantage plans may have a monthly premium, which must be paid above and beyond the Medicare Part B monthly premium. Medicare Advantage plans will have a number of payment options, including taking a deduction directly from your Social Security payment, a coupon payment book, automatic bank deduction, a deduction from your Railroad Retirement Board check, as well as credit card. If you rely on Medicaid or state assistance, it may be entirely possible that you can receive assistance to defray the costs of the Part B premium and the premium of an MA/MAPD. A person should check with their case worker to see if he/she is eligible for this assistance.  Do not assume that you are ineligible, and do not assume that you will automatically be granted the assistance.  In some locations, there are Medicare Advantage plans which have zero (yes, $0) premium. Almost every state has more than one Medicare Advantage plan with $0 additional premium (you must be enrolled in Part A and Part B). Premiums have been relatively stable since the passage of the Patient Protection and Affordable Care Act (PPACA). However, the out-of-pocket costs, including deductibles and copays, i.e. cost sharing, has continued to weaken (i.e., worsen for the beneficiary, you). This is the difficulty with Medicare Advantage: ALL the terms and conditions are subject to change every year, and the premiums also change. When you add this to the terms of original Medicare worsening, it is difficult to measure the benefits of a particular Medicare Advantage against another. In some cases, certain Medicare Advantage plans are eliminated — 51 —

altogether for the following year. At that point, you have no other choice than to choose a new Medicare Advantage plan, or one will be chosen for you. Deductibles and Coinsurance Each Medicare Advantage plan will have its own cost sharing arrangements, a plan-specific set of terms and conditions. Those terms and conditions can require a certain schedule of payments for office visits (other than the preventative care checkup, which is complimentary under the Patient Protection and Affordable Care Act), hospital stays, skilled nursing care facilities, durable medical equipment, and everything else under Medicare Part A and Part B.  Please know that the schedules must be fully detailed in your Summary of Benefits guide, and that the coverage that you receive in an MA or MAPD must be at least as good as the benefits that you receive under original Medicare. Lastly, there will be an annual out-of-pocket maximum amount. That annual out-of-pocket amount does not include amounts charged above the Medicare “allowed charge.”  The Medicare “allowed charge” has been described in Chapter 3. Certain Medicare Advantage plans address by the fact that they do not allow providers to charge any additional amounts to Medicare Advantage beneficiaries. All Medicare Advantage plans have received official approval from the CMS (Centers for Medicare & Medicaid Services). The cost sharing terms and conditions have been approved by the Centers for Medicare & Medicaid Services (CMS). Those amounts will limit your out-of-pocket expenses to a certain degree.  In-Network vs. Out-of-Network The most important aspect of Medicare Advantage (MA) coverage is the concept of network. Most people have experienced a network of some sort, whether that is in the form of your employer’s group health insurance plan, or private health insurance.  For MA, a similar concept applies. When you receive services from providers inside the network, cost — 52 —


sharing is reasonable. Outside the network, however, cost sharing greatly increases the out-of-pocket deductibles, copays, and annual out-of-pocket maximums. That is why it is important to check the physicians that you visit, as well as those that you might be reasonably expected to visit.  Doctors may or may not accept a particular Medicare Advantage plan; do not presume that your doctor will accept your Medicare Advantage plan, even if he/she accepted your employer’s plan in the past, and even if he/she accepted insurance from the same carrier before you were under Medicare.  It is entirely separate, and you need to check this for yourself (or with an agent’s assistance).  HMOs, in particular, deserve very specific examination, because you can only go to a specialist after receiving a referral from your primary care provider (PCP). That specialist must also belong to the network. For PPOs, out-of-network providers will accept your Medicare Advantage plan, but you will be charged a different amount for services received. In addition, the annual out-of-pocket maximum is notably higher if you use out-of-network providers. One thing that you must keep in mind is that if you travel on vacation, and you require medical attention, then that provider may or may not be inside the network. This Happens. A “snowbird” (a person that goes to warm weather locations during the winter) may vacation for extended periods of time.  However, when that person goes to his/her physician in Arizona (or Florida, etc), the physician may not belong to your network, and your outof-network cost sharing arrangement would apply.  That will be far more expensive than in-network, and the price differential can be so great, that it would have justified more comprehensive coverage via another selection. This Happens. — 53 —

Not all insurance companies are equal, of course. Some are far more dominant in particular states, or in your particular location.  Others are more national in scope and scale.  You should think carefully if you are going to choose a Medicare Advantage plan, and check your medical providers in advance in order to minimize your out-of-pocket costs. Most of the time, the insurance companies have online directories, so you can search for your providers, or you can ask your insurance representative/ agent for assistance.  In addition to that, you will be faced with a very complicated situation with respect to annual out-of-pocket maximums if you are enrolled in a Medicare Advantage plan.  The reason this occurs is because some of your expenses will be in-network, and some will be out-of-network.  You will need to keep track of your visits, and the charges, and reconcile your statement of benefits that you receive from the insurance company that issued your Medicare Advantage plan. That alone is the source of great confusion because then you will basically be forced to verify your Medicare Advantage’s records by comparing them to bills received. Annual Notice of Change (ANOC) Every year, both Medicare Advantage plans and standalone prescription Plan (Part D) beneficiaries will begin to receive an annual notice of change, a regulatory requirement mandated by the CMS. The ANOC will contain detailed information regarding coverage you have received in the current year, and will display how it will change in the following year. For example, the ANOC will display changes in premiums, deductibles, and copays, which may vary from year to year, depending on the services that you receive. It cannot be overstated: beneficiaries should read these ANOCs when received. Too often, beneficiaries discard this document, and learn, after the fact, that their out-of-pocket costs change at a time they least expect. A very important feature about ALL Medicare Advantage and Medicare Part D plans is that they are annual contracts, these plans are approved by the CMS on an annual basis, and can be greatly affected by a large — 54 —


number of factors. Last (and not least), the carriers of Medicare Advantage Plans and Part D plans are actively competing against one another. The result is that the terms and conditions of your Medicare Advantage or Medicare Part D are likely to change, and those changes can affect the cost of the coverage and services you receive. How to Compare Medicare Advantage Benefits The improvements in Medicare Advantage, since the first edition of Maximize Your Medicare, have been dramatic. Networks have expanded, access to specialists can occur with referral, prescription drug benefits can exceed standalone Part D plans, health and prescription deductibles can be as low as $0. If anything, this has made it more difficult to tell exactly which Medicare Advantage plan is best. Deductible. The stunning development in 2018 is the increased evidence of lower health and drug deductible. There are now Medicare Advantage plans with health deductibles $0. This is very valuable to the millions of people who live on a fixed monthly income, and are required to plan their monthly spending budgets carefully. Part B Premium Rebate. For enrollees in certain Medicare Advantage plans, a portion of the Part B premium ($134 a month for new enrollees) can be rebated, in the form of a higher Social Security benefit. It is important to note that those that receive governmental assistance for Part B premiums, resulting from Medicaid payments, are not eligible. Hospital stay copay. There are two ways that most MA offer cost sharing if you are admitted to the hospital.  You should choose the copay that is a given cost per stay, and not the deductible that charges per day. Why is that? Simply put, you usually get admitted to a hospital for longer than a simple overnight stay. So when you multiply the per day copay times the number of days, that is usually more than the copay that is charged by those plans that charge on a per stay basis. All else equal, the premium will, on average, be slightly higher, but the fact is that if you stay at a — 55 —

hospital for multiple days, then you will save money by choosing an MA plan that charges you per stay. Office visits. If there is a plan that does not distinguish between your family physician and a specialist, then that should be chosen, since an office visit to a specialist may be substantially more expensive than an office visit to your family doctor. In addition, remember that your annual examination is free, as a result of the Patient Protection and Affordable Care Act (PPACA). Extra benefits. Many MA plans include discounts on dental and vision, weight-loss, and smoking cessation programs. Please know that extensive, specialized dental work, such as implants, or treatment of gum disease, are generally not covered by these extra benefits. In fact, as many know, serious dental work is usually uncovered by any type of dental insurance, or the maximum benefit is limited. Notably, observation status has already been addressed by certain Medicare Advantage plans. You can recall Chapter 2, where the principle of “Observation Status” is addressed. Under original Medicare, an inpatient status is required, and that stay must be for three days, in order to receive Skilled Nursing Care benefits under Medicare Part A. However, some carriers have altered this in a very positive way, because beneficiaries of certain Medicare Advantage plans can receive Skilled Nursing Care benefits without a 3-day inpatient hospital stay. The pressure on the Medicare system as a whole has resulted in the elimination of certain treatments/consultations, or limited the inclusion of others. One type of treatments being limited is chiropractic treatments. Certain Medicare Advantage plans cover chiropractic services, which original Medicare does not. In addition, that can also include physical therapy. Certain Medicare Advantage plans provide benefits for physical therapy above and beyond original Medicare. Five-Star Plans. The CMS rates plans every year. It is beyond the scope of this book to discuss how it reaches its determination. The plans are given a number of stars between 1 and 5.  You can switch into a plan that — 56 —


has been given five stars by the CMS at any time during the year. This is a new Special Enrollment Period (SEP). You can switch into a five star program once, and only once, during a calendar year. Money Saving Tip #1 Medicare Advantage There is the age-old saying, “You get what you pay for.” Well, when it comes to Medicare Advantage, there is a new twist, and it goes, “You don’t always get what you pay for, but you always pay for what you get.” What in the world does this mean? It means that if you compare carefully, side-by-side (apples to apples, whatever), then you can find, even within the same company, that you can save premium, without a substantial decline in benefits. Maybe you have the time to compare by yourself, or maybe you know an expert, or a professional. If you read the previous section, then you will find that you can obtain policies with similar out-of-pocket expenses and save $30-$50 a month. Maybe you think that isn’t very much money. Now start multiplying by years and you will see the figures quickly increase. Anecdotally, people don’t like change. They stay with the same plan if things do not change dramatically within their own plan. However, you need to remember that there is intense competition among insurance companies. You should absolutely use that to your advantage (no pun intended). Academic studies have concluded that consumers leave 10% a year in cost on prescription drug plans due to this behavior (lack of changing to more efficient plans). My thought is that this also occurs when it comes to Medicare Advantage plan selection. Take 10% a year, and start multiplying by years that you will live, and you will get the picture. Of course, there are limits to this point, i.e. it is not the recommendation of Maximize Your Medicare that you change physicians every year in order to accommodate your Medicare Advantage plan. Nevertheless, not shopping around will cost you money, or benefits.

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NOTES PAGE ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������

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 MEDIGAP (MEDICARE SUPPLEMENTAL) Truths and Myths Truth: Medigap benefits are stable through time, i.e. benefits do not change from year to year. Premiums are likely to increase with age. Truth: Initial enrollment, when turning 65 years old, into Medigap is easy, but enrolling in Medigap later can be based on your health at that time. Myth: Medigap premiums increase at the random choice of the carrier. There are regulations that require carriers to spend at least 80% of premiums on claims. Now we proceed to look at Medigap, otherwise known as Medicare Supplements, or Medicare Supplemental insurance. They are three different terms but they are all the same thing; they all describe the same set of plans.  You will need to be enrolled in both Medicare Part A and Part B. This chapter will describe the general terms and conditions of those plans, as well as the enrollment timeline.  The conclusion will be that Medigap plans, along with a stand-alone prescription drug plan (PDP) may be better for you than any other configuration that exists in the market today. It will be up to the Medicare beneficiary to determine if the higher premiums are “worth it,” when compared to Medicare Advantage.

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Medigap Enrollment Medicare Open Enrollment The Medigap open enrollment period is not the same as the Medicare Initial Enrollment Period. The Medigap open enrollment period begins on the first day of the month that you become eligible for Medicare Part B, and it lasts for six months. For Medicare Advantage as well as Medicare Part D (stand-alone prescription drug plan), this is a very important fact to keep in mind.  Remember Jane Doe, born on February 13, 1948?  She turns 65 years old on February 13, 2013. The way that Medigap open enrollment period works is her open enrollment period begins on February 1, 2013 and it lasts through July 31, 2013.  This may seem strange, since the Medicare Advantage (Medicare Part C) open enrollment period begins on November 1, 2012.  Depending on the state, you can apply prior to the beginning of the Medigap open enrollment period. Huh?  February 1, 2012 is the regulated beginning of Jane Doe’s Medigap open enrollment period, but she may be able to apply in advance. That will depend on the state and/or insurance company.  An easy rule of thumb: when the Medicare Initial Coverage Election Period (ICEP) begins, you can usually sign up for Medigap. In theory, you could have Medicare Part A and Part B only, wait for five more months and then you could enter into Medigap with no penalty. It is also possible that you originally enroll in a Medicare Advantage plan for up to one year, and exercise your Medigap open enrollment rights under a separate SEP. Please note: even if you deliberately wait until the end of the Medigap open enrollment period, nothing changes the Medicare Part D open enrollment period. For our Jane Doe, the last day to enroll in Part D is May 31, 2012, regardless of the date that she applies for a Medigap policy.

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Medigap Open Enrollment Rights During the Medigap open enrollment period, you are guaranteed to be issued the Medigap policy of your choice. You are entitled during this very special time; If you are seriously ill with a known condition that requires constant medical attention, use the Medigap open enrollment period because you are most likely going to be denied Medigap coverage in the future, unless you know that you qualify for an SEP (Special Enrollment Period). During the Medigap open enrollment period, insurance companies cannot deny you coverage, nor can they charge you a higher price based on your medical situation. While insurance companies are obligated to accept you, however, they can charge different prices based on biological sex. It is reasonable to anticipate that this will continue.   Enrolling in Medigap During Other Periods Guaranteed Issue (Medicare Protections) Guaranteed Issue is slightly different than Medigap Open Enrollment. You will be able to select a subset of Medigap plans if you are entitled to a Special Enrollment Period (SEP), as described in Chapter 5. You can enroll in Medicare Part A, Part B, Part D, and a certain set of Medigap plans without restriction. This period ends 63 days after your other coverage ends. Hint: it is wise to enroll in advance of this, because otherwise, you would be subject to medical underwriting. The plans that you can elect are Medigap plans A, B, C, F, K, and L. Carriers are required to offer these plans to you, if the carrier offers these plans to other applicants. If carriers do not offer a particular plan (for example, Plan F) to other applicants then it does not have to offer it to you under Guaranteed Issue. Solution: find another carrier that does offer the plan you wish to elect. One more thing to note: carriers, at their sole discretion, can elect to offer more plans than this if you qualify for a Special Enrollment Period.

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Switching From One Medigap Policy to Another This is possible. However, you will be subject to medical underwriting.  An insurance company can choose to accept or deny coverage based on your answers to medical questions.  However, it is very important to avoid errors. Different carriers will have very different decision-making processes. For example, insulin-dependent diabetics or those that have taken certain painkillers may be automatically denied by one carrier, but not by another. The net result is that you cannot randomly apply to many different carriers. The reason for this is that if you are denied by a particular carrier, then that can become part of your shared record via the MIB Group (see a further description in Chapter 9), and that can result in denials from other insurance companies. Many people wrongly assume that you can switch Medigap carriers only during the Annual Election Period. That is not true; you can switch from one Medigap carrier to another at any point throughout the year. Switching From Medicare Advantage to Medigap If it is during the Annual Election Period (AEP), this is possible, but you are subject to medical underwriting. An insurance company can choose to accept or deny coverage based on your answers to medical questions. If your Medicare Advantage does include prescription drug benefits, then you should wait for the Annual Election Period, because you will be canceling your prescription drug benefits, and you cannot enroll in a standalone prescription drug plan (Medicare Part D) until the Annual Election Period (AEP). If you cancel your Medicare Advantage plan during the Medicare Advantage Disenrollment Period, which runs from January 1st through February 14th, then you can cancel your Medicare Advantage Plan, and return to original Medicare, which means that you can select a stand-alone prescription plan (Part D). You will need to be very careful because your application to Medigap may be subject to medical underwriting. — 62 —


The most practical way of switching is to first be accepted by Medigap, and then choose to disenroll from your Medicare Advantage plan, which will allow you to enroll in a prescription plan through the Medicare Advantage Disenrollment Period SEP. How Medigap Works with Original Medicare Medigap plans come with letters A-N. The different plans, what they cover, what they do not cover; it is in the chart at the end of this chapter. Every Medigap plan must at least cover what Medicare Part A covers. This section highlights the benefits you receive as a Medigap policyholder. Medigap and Medicare Part A  You can see in Table 4 that every Medigap plan will pay, either in full or in part, the Part A deductibles. That makes every Medigap plan vastly better than original Medicare. You may remember from the Chapter 2 (on Medicare Part A), that the deductible for hospital admission is $1,340.00 per benefit period.  In all plans except Plan K, Plan L, and High-deductible Plan F, the entire deductible is paid. This compares very favorably with original Medicare and Medicare Advantage plans. In addition, all Medigap plans will cover at least 50% of the copay amount from days 21 to 100 in a skilled nursing care facility. For example, if you have a joint replacement surgery, and you enter a rehabilitation center for a period longer than expected, then your Medigap plan will cover at least 50% of the $167.50 a day that the Medicare system does not under the current system.  The $167.50 per day copay for days 21-100 is reset annually, so the daily charge may be larger through time. Again, this is favorable when compared to Medicare Advantage, which may require a copayment on a daily basis. The cost sharing terms of admission to a skilled nursing care facility will continue to increase. This should make intuitive sense; it is very common

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for people to receive joint replacement surgery as they age, and that requires rehabilitation. More people requiring rehabilitation means higher demand, which means prices. Period. The lack of a coordinated approach to housing our aging population is a well-known problem without a solution at the current time. The net result of these factors? Higher prices. Medigap and Medicare Part B With respect to Medicare Part B, you can see again by Table 4 that many of the Medigap plans cover most, if not all, of what is not covered by the Medicare Part B. For example, the C and F plans cover the annual deductible, which will be $183.00 in 2018. Again, please note that if a plan covers the Medicare Part B deductible and the Part B deductible increases, then that plan will cover whatever the Part B deductible is for that year.  Coinsurance that accompanies Medicare Part B is paid in full by all Medigap plans except K and L, in which the Medigap pays 50% (or 75% for Plan L) of the 20% that original Medicare Part B does not pay.  For all other plans (except for High-Deductible Plan F which is described later in this chapter), a Medigap policy pays for the entire 20% that is not covered by Medicare Part B. One particular Medigap plan (Plan N) charges a fee per office visit. You can see it’s a maximum of $20 for most office visits. To be clear, the annual preventative care examination is still free, in accordance with the Patient Protection and Affordable Care Act (PPACA). The $183.00 Medicare Part B deductible is for services received, but not the annual preventative care visit. The complimentary annual preventative care visit is governed by the Patient Protection and Affordable Care Act (PPACA). For emergency room visits, it is a $50 per visit to an emergency room, which is refunded to you if you are admitted to the hospital, because then you would fall under Part A.

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A Few Exceptions You will notice that not all letters are represented because some plans have been discontinued by the Medicare system. All plans are authorized by the CMS, the Centers for Medicare & Medicaid Services. The terms of coverage for the different plans are identical across all insurance companies whether that insurance company is Aetna, Transamerica, etc. Since they are all identical to each other, you can compare prices easily. Generally, this should be the source of great comfort to consumers. However, there are some twists to this, and they will be addressed at the end of this chapter.  One is called the pre-existing condition waiting period. Medicare SELECT In some states, you may be able to buy another type of Medigap policy called Medicare SELECT. SELECT plans provide coverage using the same terms as other Medigap policies, but they may require you to see certain providers. The result is that the premium may be less than standard Medigap plans. You can be charged more if you receive services that are not part of a pre-specified list. Hint: the lower premium presumes that you stay within the network. That is eliminating a major advantage of Medigap. You should carefully compare whether the premium savings are worth the network limitation. In 2017, there were multiple instances where list of network participants in Medicare SELECT changed within the calendar year. The bottom line is that unless the cost savings is worth choosing a Medicare SELECT plan instead of a standardized Medigap plan, the standardized Medigap plan is superior because all healthcare providers that accept Medicare (the red, white and blue card) will accept your Medigap card. Attained-Age vs Issue-Age vs Community-Age There are three different pricing mechanisms for Medigap policies. They are attained-age, issue-age and community-age.  In reality, they are quite straightforward to understand.  The availability of the different types of

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plans varies depending on your state. This book will address the three types in order of popularity. Attained-age. Attained-age has a separate price depending upon your actual age. Let’s revisit Jane Doe, who becomes eligible on February 1, 2013.  She will be offered a price for a 65-year-old woman.  Depending upon the insurance company, the premium may stay constant for a pre-stated period of time. Insurance companies have the right to change premiums as long as they can prove that claims are 80% of the premiums minus administrative and other various charges. The important fact is that when Jane turns 66 years old, she can be charged a different premium. She cannot be charged a different premium based on her individual claims (a FAQ by many). Under attained-age, you can experience multiple increases in a year. How? Let’s say you turned 65 in May, and offered a 12-month premium lock. When you turn 66, you would be charged the premium of a 66 year old. If the carrier changes its overall rates in August, then you could be charged a new 12-month premium in August. That is entirely possible. Community-age has a single price regardless of age.  It does not differ whether you are 65 years old or 80 years old. This has an obvious advantage, which is that as you get older, it may make sense to have a community-age based Medigap policy, if you are allowed to do so. That said, the premium of a community-age policy should be expectedly higher than the attained-age policy for the same person who is new to Medicare. The other issue to consider is that even though the price is not different if you are 65 or 80 years old, the price for the entire community of policyholders may increase as a whole. Issue-age policies are priced when you first purchase the plan, and the price does not change.  Like community-age policies, issue-age policies have a price that is initially higher than the more popular attained-age. It is almost impossible to predict which type of pricing will work out best over the long run. On one hand, lower premiums are undoubtedly better, all else being equal. That would imply that attained-age is best. In — 66 —


addition, you may think, “Well, if I don’t live that long, then I don’t have to worry about the much higher premiums at much later ages.” This line of reasoning is intuitively attractive, to be certain.  On the other hand, if there are structural changes to Medicare, such as dramatic changes to the coinsurance and copays (cost sharing), then premiums that do not increase may be the superior solution. In addition, there are certain locations where a particular insurance company issuing a community-age Medigap policy cannot raise rates for a specified period of time. That, of course, is the best of all worlds, especially if the Medigap plan is the one that you prefer.   Base Case: Medigap is Superior If you read the introduction to this book you can remember that my main objective here for you is for you to avoid catastrophic losses. Some events, like a hurricane, cannot be anticipated. Of course, no one wants to get ill. However, if it occurs, as is more likely as you naturally age, then catastrophic losses can add up, and cost you a significant portion of your retirement savings. No one can avoid the natural aging process, and the increased likelihood of getting ill that accompanies the passage of time.  If you can afford it, then Medigap and a stand-alone prescription drug plan is best, particularly when you first become Medicare-eligible (this is also described in the Experts’ Addenda).  Even a Medigap Plan N is superior to most MAPD plans, for very similar prices. At the end of the day, Medigap plans do a superior job of covering Medicare Part A costs under original Medicare.  If you enter into a situation when the Part A deductible or coinsurance are due, then Medigap will end up saving you money, and there is no concept of network, the point mentioned earlier.  For those of you that don’t like the guesswork of calculating how much you will owe when you receive medical services from your physician, Medigap provides clarity and consistency. The benefits provided by your Medigap policy next year will be calculated the same way it is calculated this year.    — 67 —

Advantages of Medigap Why would I recommend so strongly for persons to enter into a Medigap policy as soon as they are able to do so? The answer is that once you are out of your Medigap open enrollment period, individual insurance companies are able to ask questions regarding health, and deny your application. There may be some selected companies that will accept you, even if you have pre-existing conditions. Those are the insurance companies that you will want to avoid, if you can, due to the way in which insurance companies establish their premiums. For example, many insurance companies will not offer Type 1 diabetes patients Plan F after the Medigap open enrollment period ends. Even under a Special Election Period (SEP), individual insurance companies may be allowed to deny coverage under certain plans, as long as they offer Plan A, and one of Plan C or Plan F. If your group plan ends, for example, you will have the right (for up to two months after that plan is canceled/discontinued) to enter into a Medigap policy under a Special Election Period. In addition to the ability to purchase a Medigap policy, the SEP will allow you to enter into a stand-alone prescription drug plan (PDP/ Medicare Part D). Update: this will substantially worsen in 2020, when the “permanent doc fix” will eliminate Plan C and Plan F. The result is that those who are “waiting to enroll in Medigap,” have lost two powerful options as a result of this legislated change. This will almost certainly be a negative surprise to many. Unless there is additional legislation or regulation to correct this, this means that there will be no Medigap plans available under Medigap Guaranteed Issue provisions which cover the Part B Excess. This Happens.  A 67-year-old is informed that his retiree health insurance plan is going to be canceled by his employer.  He faces two issues. First, he is protected by Guaranteed Issue rights, which allow him to enroll in — 68 —


Medigap plans A, B, C, F, K and L. That also means there are certain plans that are not protected by Guaranteed Issue rights. That means his choices are wider during the Medigap open enrollment period. Even if he were in perfect health at 67-years-old, the plan that he originally wanted may not even exist at the time that he wants to change into Medigap. Remember that the design of Medigap policies is governed by the Centers for Medicare & Medicaid Services (CMS).  That means that CMS also has the right to discontinue plans; it has done this in the past.  Plans D, E - a prime example is E - H, I, and J Plans no longer exist (although original policy owners still can use their plans as long as they continue to pay premiums). This Happens.

No Network, No Annual Election Period Unlike Medicare Advantage plans, Medigap has no concept of network at all. If your medical doctor or medical provider accepts Medicare, then they’re required to accept Medigap.  Sometimes, you will get pushback from a secretary or billing coordinator, who asks you what Medigap plan you may have. This is actually quite annoying for a billing professional to ask, because that actually isn’t a relevant question. It isn’t even a question that they should be asking you. At the risk of being repetitive, if a doctor or medical provider accepts Medicare, they are required to accept your Medigap policy, regardless of location. Foreign Travel One other additional point is that many of the plans under Medigap actually allow for foreign travel emergency services.  There is a $250 deductible. Your Medigap policy will pay for 80% of your emergency travel medical expenses, up to a lifetime maximum $50,000. You are responsible for the remainder of the bill. Candidly, you will probably need to wait to be reimbursed. It may be cumbersome, from a practical point of view,

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to file a claim while you are in a foreign country, so you will be able to file claims with your insurance company after you return home. Medigap and Part B Excess Charges Earlier, the Medicare Part B Excess were explained. Recall that a medical provider can charge up to 15% more than the Medicare-allowed charge, and the out-of-pocket costs can be very high. Under Medigap Plans F, High-Deductible F, and G, the Medicare Part B Excess Charges are covered in full. If you have Plan F or plan G, and the doctor charges more than the Medicare “allowed charge,” then your Medigap will cover this amount.  For high-deductible Plan F, the Part B excess charges are paid after you meet the annual deductible, which is $2,240.00 in 2018. We need to examine this particular piece of information, because generally speaking, Plans F and G are more expensive than the other plans. Now, the question is, is the protection provided worth the cost?  On one hand, these plans can be approximately $400.00 more per year in premium than other Medigap plans. There is no doubt that this is a lot of money.  However, if you are a person with an incurable disease, such as Parkinson’s disease, diabetes (Type 1), cancer, Rheumatoid Arthritis, Congestive Heart Failure, or Multiple Sclerosis, then you are facing a fairly long period in which you will require extensive medical attention. If you suffer a heart attack requiring open heart surgery, or if you suffer a stroke, then again, there will be a long, difficult road to recovery.  If one episode occurs like this in your lifetime and you incur an Excess Charge, the $400.00 dollars a year can be paid many times over, depending on the treatment required.  In addition to the financial considerations, there is also the emotional aspect that has not been mentioned in this book, as yet.  People who face serious medical conditions require not only their own strength, but the strength their family and friends.  It could easily be said that there is almost no price tag that can be put on peace of mind. There will not be — 70 —


an endless trail of medical bills, there will not be any worries about how to pay, and there will not be any thoughts about the financial costs on those around you.   Standardization and Grandfathering The previous example highlights two important features of Medigap policies. Let’s call them standardization and grandfathering. By standardization, the coverage for all Plan N’s is the same, regardless of insurance company. That makes it easier for medical provider administrators/billing personnel to understand.  The idea of language that changes from company to company or hidden language simply does not exist. The second and potentially more important reason that a Medigap policy is superior to any other policy is because of the grandfathering characteristic. This is known as “Guaranteed Renewable.” As long as you continue to pay premiums then the policy remains in effect as it was originally written, unless it is changed by the CMS. The only party that can cancel your policy: you. In the past, the Medicare system has discontinued plans but has allowed persons who were originally enrolled in that plan to stay with the same language. That is very important, largely because of the fact that we may anticipate, or reasonably predict, that the Medicare system will change in the future. As you may have read, doomsday predictions suggest that the Medicare system will be insolvent as soon as 2018.  For the record, this isn’t a plausible scenario (the most influential voting bloc is over 50 years old). However, it is entirely possible, if not probable, that certain plans may be discontinued in the future. As of this writing, this has now occurred: Medigap Plan C and Medigap Plan F will no longer be available to new applicants, beginning in 2020. The point?  There is no better time than now to lock down the coverage, which would take advantage of the grandfathering characteristic (mentioned in the previous section) that you will desire over the long run. If you wait for that period of time to arrive before changing, you may be — 71 —

rejected for medical reasons, or perhaps, the plan that you desire may not exist at all. When Is Medicare Advantage Better Than Medigap? More comprehensive medical coverage and consistency of costs are the two largest reasons for choosing Medigap instead of Medicare Advantage. However, there are some situations in which Medicare Advantage may be the better option. During Chapter 6, you will see that Medicare Advantage has notably improved in important ways. As mentioned earlier, Medicare Advantage can offer additional benefits, such as discounts for smoking-cessation programs, weight-loss programs, and vision and dental discounts, among others. While in the short run, these may give you some satisfaction, you will quickly forget your discounted trips to the fitness center if you are admitted to the hospital and have large out-of-pocket expenses. You can compare the cost sharing of Medicare Advantage, to Medigap, and see for yourself. You Are Financially Stretched The phrase Maximize Your Medicare does not mean “minimize your food.”  It is another way of saying that I am not advocating you becoming “insurance poor.” You need to eat, pay bills, and live. There are other priorities in life as well. Perhaps you have to support someone else. Maybe you think it is more important to buy clothes for your grandchildren. It isn’t the role of Maximize Your Medicare to determine this for you. On the other hand, remember that you need to be in good health in order to contribute to others. That is for you to decide. With that in mind, there are reasons that Medicare Advantage could be a superior choice when compared to Medigap. You can easily find Medicare Advantage plans that are cheaper than Medigap. MA is convenient, especially because prescription drug benefits are frequently combined with medical insurance. If you receive prescription

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drug benefits from another source, then the price of an MA plan without prescription coverage may make sense. In certain states, HMOs actually rebate you part of your Medicare Part B premium. While the Part B Excess has been explained, and the risks have also been explained, you may be willing to accept that risk and the inferior cost sharing arrangements of Medicare Advantage because you need to save the extra money. One objective of this book is to point out that Medigap policies can be found that are essentially the same price as Medicare Advantage plans, and that due to the consistency of coverage, along with unwritten implications, Medigap is superior to Medicare Advantage. All else equal, then, Medigap would be the better choice.  However, “all else equal” may be language that does not apply.  At some price, it may be worth it to accept the inferior cost sharing terms within Medicare Advantage plans. Financial priorities may dictate your choices. This is your private, financial reality; this book is written so that you know what the risks are of the choices that you make. You Are Well Over 70 Years Old The most popular, most widely available Medigap plans are attained-age, as described earlier in this chapter. Medicare Advantage plans are entirely community-age based. That means that premiums of Medicare Advantage do not change, regardless of age.  They are reset every year, and it doesn’t matter if you are 65 or 85, the price is the same.  It may be that the price differential between Medigap and MA, when you reach advanced ages, makes a change from Medigap to MA a very good idea. However, remember that the conditions stated in the previous section (“Base Case: Medigap is Superior to Medicare Advantage”) are still true. The language will change and the premium will change every year, and the Part B excess remains uncovered. It is not easy, and depends very much on the amount of financial resources you have. If you cannot afford the premiums, and find that you are being stretched financially as a result

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of Medigap premiums as you reach an advanced age, then a change to an MA plan may be a good idea. You Always Stay Close to Home As stated above, one drawback of Medicare Advantage is the idea that there is a network. Cost sharing is worse if you want to receive services from a provider that is not in your network. In extreme cases (as in an HMO), you would need to bear the entire costs not covered by original Medicare. In other cases, receiving services from an out-of-network provider can be double the cost when compared to receiving services from an in-network provider. It is this book’s conclusion that this will worsen over time, and in some cases, dramatically. However, if you do not travel at all, and your providers are the same ones that you have used for a long time, and the facilities in your area are ones that will not change, then you may not use the advantages that a Medigap policy offers. In that case, perhaps the extra benefits that often accompany an MA plan are more worthwhile than the flexibility that you get due to absence of a network. That is entirely possible if you don’t travel away from home. Medicare Advantage Extra Benefits Medicare Advantage carriers have done well to add discounts to health clubs, exercise equipment and other heath & wellness benefits to their plans. These can include dental and vision benefits. Chiropractic services are currently not covered under original Medicare. However, treatment of subluxation is frequently covered by Medicare Advantage plans, with a copay. In addition, such as neurologists, often conduct consultations, which are not covered by original Medicare, but may be using Medicare Advantage. In Chapter 5, the section “What to Look For When Choosing Medicare Advantage” mentions that certain Medicare Advantage plans have cre-

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atively addressed the confusion and controversy surrounding observation status, and subsequent Skilled Nursing Facility care. Money-Saving Tips on Medigap Enroll in Medigap Early Let’s start with a little review. A fact mentioned earlier in this chapter is that insurance companies will allow you to enroll in a Medigap policy well before your first date of Medicare eligibility. Do you remember Jane Doe? Her first date of Medicare eligibility is February 1, 2013. Her Medigap open enrollment period begins February 1, 1948, but certain insurance companies frequently allow clients to apply for Medigap well in advance of that. In addition, insurance companies may allow her to pay premiums well in advance.  If you have the ability to do so, then you can pay before the premium increase takes effect by enrolling early, by enrolling before price changes are announced. Renew Your Medigap Early Every year, Medigap premiums generally change on January 1 (and then again when you change attained age). Usually, those rates are established sometime during the end of the year. For example, you can expect insurance companies to post their rates for 2018 sometime during November through December. However, many insurance companies will allow you to pay your premiums in advance, for up to 12 months. If you have the resources available, then you can avoid a year’s increase by paying your premium in advance, for as far as you can, and as far as your insurance company will allow. High-Deductible Plan F May Be a Bargain There are only 3 plans that will cover the Medicare Part B Excess. They are Plan F, Plan G, and High-Deductible Plan F.  High-Deductible Plan

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F is not offered by all insurance companies, but it may represent quite a bargain. The cost sharing mechanism is different than the other plans. If you purchase a High-Deductible Plan F, then you are responsible for the first $2,240.00 of costs. That amount is set annually by the CMS. However, once you have met this deductible, then the High-Deductible Plan F will pay for all costs.  There are no further copays or coinsurance. In addition, the Part B Excess will also be paid by this policy. Is this a deal? That depends. If you have outstanding health (no medications, annual doctor’s visits for maintenance), and are at an advanced age, then the answer could be yes. High-Deductible Plan F puts an absolute cap on your medical costs (except prescriptions).  If you have financial difficulty but want “disaster insurance,” then this may be a better use of money, compared to Medicare Advantage, because it covers the Medicare Part B Excess. You will need to calculate the annual premium, and compare it to the alternatives. The way to evaluate this is to divide the deductible by 12, the number of months, and then add that number (let’s call it X), to the premium of the high-deductible Plan F. For 2018, the deductible is $2,240.00 so X = $181.67. Add that to the high-deductible Plan F premium, which is approximately $105.00/month for a 70-yearold. So, the total of $286.67 is the absolute worst case scenario. In this case, it is more probably the case that you experience some type of Part B excess change. That will be paid for by the high-deductible Plan F. Medigap Open Enrollment During Q4? This is a very specific situation, and should be handled with care. For those enrolling in Medigap for the first time during the last three months of the year, you can take advantage of the calendar. First, you should enroll in Plan F. The reason? You do not have to pay for the Part B deductible. That way, you can get not only the preventative care examination, which is free, but you can also receive any follow-up treatments, and the Medigap policy will pay for potential out-of-pocket expenses. It gets better. Let’s say that you believe that Plan F is too expensive. You will have the unrestricted right to change Medigap plans to a cheaper — 76 —


one, as long as you are still within your Medigap Open Enrollment Period, which doesn’t end until you are 65 ½ years old. Pitfalls to Avoid When Choosing a Medigap Policy Pre-Existing Condition Waiting Period This quote is from “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” from the Centers for Medicare & Medicaid Services (CMS). “Remember, for Medicare covered services, original Medicare will still cover the condition, even if the Medigap policy won’t cover your out-of-pocket costs, but you’re responsible for the coinsurance or copayment.” Insurance Companies Can Impose a Waiting Period The source of this information is the Centers for Medicare & Medicaid Services.  “While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage related to a pre-existing condition. A preexisting condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out-of-pocket costs for these pre-existing health problems for up to 6 months. This is called a ‘pre-existing condition waiting period.’ After 6 months, the Medigap policy will cover the pre-existing condition. Coverage for a pre-existing condition can only be excluded in a Medigap policy if the condition was treated or diagnosed within 6 months before the date the coverage starts under the Medigap policy. This is called the ‘look-back period.’” What This Means If you are becoming Medicare eligible, then you have the right to choose any Medigap provider available in your state. However, after the end of the Medigap open enrollment period, then you may need to medically — 77 —

qualify (i.e. you may be asked questions about your medical situation). Important note: If you have had health insurance continuously for the 6 months prior to Medicare eligibility, then no insurance company can deny you coverage under this stipulation. It may be important to avoid choosing a carrier that imposes the “pre-existing condition waiting period.” If you want to know which companies these are, here is a HINT: find the companies that offer teaser rates. The teaser rate ends, there is a pre-existing waiting period, the waiting period ends, and then, in certain cases, you are unable to change providers. Teaser Rates If you are turning 65, then you are receiving teaser rates. You will receive a LOT of advertisements regarding Medicare Supplemental insurance (Medigap), the way that Medicare works, and different options. Often, you will receive lower initial monthly premiums. However, there are problems related to these low, initial prices. You Can Change Medigap Carriers Anytime, UNLESS... If you are unsatisfied with your Medigap insurance for any reason, you can change plans or companies at any time. However, if your health deteriorates, and you develop a medical condition, then you may be not be accepted by the new insurance company. Pre-existing conditions may be a factor once out of the open enrollment period, depending upon the company, and the Medigap policy selected. This Happens.  A 65-year-old gentleman chooses a Medigap policy from a company with a low initial teaser-like rate. After two years, he is diagnosed with cancer. The low initial rate expires, and large rate increases occur. The man decides it is too expensive, but he may not be able to change Medigap policies. Now, the fact is that some companies — 78 —


MAY allow you to change, and some MAY NOT. You will need to check for yourself. Just be careful because the teaser rates may be too good to be true. However, this gentleman can switch to Medicare Advantage during the Annual Election Period.  This Happens. Medigap Birthday Rule In certain states, there is a “Birthday Rule,” which allows a current Medigap policyholder to switch carriers to an equivalent or weaker Medigap plan at a different carriers, without medical underwriting. As of this writing, California and Oregon are the only two states with this provision. How to Avoid Pitfalls Although there are no magic answers, here are some very good starting points.  First, eliminate companies that have the Medigap pre-existing condition waiting period. It makes no sense to become Medicare eligible, knowing that you require some treatment, and waiting for Medicare, just to have coverage by your Medigap policy denied during this waiting period. If your medical situation deteriorates during the first 6 months after enrolling in Medicare, and you require extensive medical attention immediately, then the amount not covered by Medicare Part A and Part B can be large. You will be liable for the cost sharing under original Medicare. Remember that if you have had coverage for the 6 months prior to Medicare eligibility, this stipulation does not apply to you. Second, remember that an agent/financial representative may be able to help. You can distinguish an agent who has actual expertise of details by simply asking if the insurance company has the pre-existing condition waiting period. If the agent is unaware of the meaning of this waiting period (and there will be many who are unaware), then you need to find another agent. It isn’t your job to educate the agent. It is your job to find an agent that you believe has full command of the details that can make — 79 —

a large difference to your welfare. Third, remember that insurance companies must justify rate increases by proving a Medical Loss Ratio (MLR). In fact, as of August 2012, insurance companies have been required to issue refunds if claims did not represent a ratio of premiums (less regulatory costs).  Fourth, try to avoid insurance companies that accept high-risk patients. Admittedly, this is not a simple matter. While all insurance companies must accept you during your Medigap open enrollment period, insurance companies may deny your application enrollment if you have a pre-existing medical condition. Nevertheless, some companies may accept you. If you do not have a preexisting medical condition, but want to change to a Medigap policy, or to change your carrier for any reason, then you should select a company that denies coverage to those that do have a preexisting medical condition.  Why is this? The reason is that your future premiums are more likely to rise at a faster rate in the future if you purchase a Medigap policy from a company that does not place restrictions on enrollment. Insurance companies can raise prices based on the claims history of the other policy owners that have the same policy. Therefore, there is no reason to enroll in a policy and be in the same pool with others that are more likely to have a greater incidence of claims, because those higher claims will justify higher premiums in the future.  Before merely choosing a Medigap policy from a carrier that charges the lowest price, this deserves careful consideration because you may be not be able to switch Medigap carriers in the future, and will then be subject to its future rate increases.  Medigap Restructuring Has Occurred in the Past The permanent “doc fix” enacted in Spring 2015 has now come true. Medigap Plan C and Medigap Plan F will not be available to new enrollees beginning in 2020.

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Certain aspects of certain Medigap plans are being examined, because they expose the Medicare system to abuse, by both patients and providers. This notion comes from a journalist on the KaiserHealthNews. org website (an excellent resource) in the article entitled, “Health Law Prompts Review Of Some Medigap Plans; Defining Who Gets Dependent Status” on August 12, 2012.  Indeed, certain Medigap plans have been discontinued in the past. Existing policyholders have continued on with their policies as originally conceived.  However, there are no new enrollees allowed into the discontinued plans. Given that Medicare is being examined, and that it is well-established that fundamental changes may be in order over time, it is reasonable to presume that certain plans may not be available in the future.  Let’s take the situation in which you wanted superior coverage, but planned to change “when I get older.” Now, that day has arrived.  What if the plan that you wanted doesn’t exist?  Was it worth it?  That will be left to you to decide.  Given that extreme medical costs are one of the two most important potentially catastrophic financial events that can occur to a household, you should consider this very, very carefully. You will be accepting a risk that could result in costs that jeopardize not only yourself, but those around you as well.  If the premium amounts are equivalent, then this is a “no-brainer.”  If you look carefully, it is very likely that you will be able to find plans which are slightly more expensive, and provide far better coverage.  Anecdotally, the error that can be seen the most is when someone tries to save $10 per month on premium. The weaker coverage ends up costing that person thousands of dollars, annually. It is much worse than that, because there is also the doubt about the future on top of the actual extra financial costs. Maybe it would have been wiser to forego one bottle of wine a month, and secure you and your family’s physical, emotional, and financial well-being.

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Table 4. Medigap Plans How to read the chart: If a check mark appears in a column of this chart, the Medigap policy covers 100% of the described benefit. If a row lists a percentage, the policy covers that percentage of the described benefit. If a row is blank, the policy doesn’t cover that benefit. Note: The Medigap policy covers coinsurance only after you have paid the deductible (unless the Medigap policy also covers the deductible). Medigap Plans Medigap Benefits











Medicare Part A Coinsurance and hospital costs up to an additional 365 days

Medicare Part B Coinsurance or Copayment




Blood (First 3 Pints)



Part A Hospice Care Coinsurance or Copayment








Skilled Nursing Facility Care Coinsurance Medicare Part A Deductible Medicare Part B Deductible

Medicare Part B excess charges Foreign Travel Emergency (Up to Plan Limits)

 Out-of-Pocket Limit** $4,960

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Plan F also offers a high-deductible plan. lf you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount of $2,240.00 in 2018 before your Medigap plan pays anything. **After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($183.00 in 2018), the Medigap plan pays 100% of covered services for the rest of the calendar year. ***Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.

Source: CMS

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NOTES PAGE ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������

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 EMPLOYER (GROUP) PLANS Truths and Myths Truth: Employer-sponsored plans are weakening as a result of demographic and financial pressure facing employers, both large and small. Truth: You may be able to delay enrollment in Medicare Part B if you are an active employee at a large employer. Truth: “Who pays first” is a complicated issue, depending on the size of the employer. Myth: You cannot change from employer-sponsored plans to a privately purchased Medicare Advantage or Medigap plan. Can I Delay Enrollment in Medicare? If you are actively working, then you may be able to delay enrollment in Medicare Part B if you have health insurance provided by your employer. It is very important to understand that prescription coverage must be independently certified by the CMS as “creditable coverage.” It is also very important to understand that while you can delay, that is not the same thing as meaning that you should delay. Chapter 8 addresses this complicated topic. When you cease working, then you will have eight months to enroll in Medicare Part B. If you delay enrollment beyond the eight-month deadline, then you will face a late enrollment penalty described later in this chapter. For employers, allowing employees to delay enrollment in Part B is probably an inefficient solution, because the effect of having a full-time employee who is 65 years old (or older) is that the group premium, as a — 85 —

whole, is higher than it would be otherwise. It is likely that you could have established other provisions to help both employer and employee by simply creating acceptable incentives for the employee to enroll in Medicare Part B and to adopt a privately-purchased Medicare configuration. Alternatively, you could establish a separate, group-Medicare policy, which may be favorable for both the employer and employees. Do not rely on others to confirm this information. Confirm it yourself by locating the language in the Summary of Benefits of the employer-sponsored plan.  Sometimes, human resource departments do not spell this out for you clearly. When you contact your human resources or employee benefit department, ask the human resources person to point out the location where the language exists in the Summary of Benefits that explains the requirement to enroll in Medicare Part B. While you can blame the human resources department for its human error, the one paying the higher cost will be… you.  It is highly unlikely that you will have any recourse to your (former) employer if the HR department informs you incorrectly. The quality of the answers that you receive can vary wildly, which is why obtaining written evidence is important. Active Employees May Be Able to Delay If you are an active employee of a large employer (>20 full-time employees) AND you are covered by employer-sponsored healthcare benefits, then you can delay enrollment in Part B until you retire or your employer-provided plan ends. If you are an active employee of a small employer, you may be required to enroll in Part B. That will depend on the employer and the terms of the group plan. You will need to check carefully because there is no one rule or regulation which governs how small employers and employees handle Medicare-eligible, active employees. The General Case For many persons, the employer-sponsored retiree plan is the best plan.  The overriding reason may be the price.  In many cases, retirees are not required to pay the Medicare Part B premium. In certain cases, — 86 —


there is no prescription drug benefits Coverage Gap, as mentioned in an earlier chapter. If this is the case, then the employer-sponsored plan may be the best option. Your total cost of protection may be lower under an employer-sponsored group plan, even if that means that there are unfavorable copayments and deductibles for health services you receive from a physician or hospital.  However, none of this solves the dilemma. The terms and conditions of your plan can change, without notice and without your input.  The problem is that your total cost can increase: your copayment and deductible schedules can all increase, and you will have no control over it. This will be governed by the agreement between the employer and the insurance company. Let’s take some real-life examples.  This Happens:  A Bankrupt Company  There is a company under the auspices of the Pension Benefit Guaranty Corporation (PBGC); let’s call it just company D. It offers a group plan for retirees, which is similar to that of a Medigap as well as a prescription drug plan, and this company requires enrollees to pay for Medicare Part B. The prescription drug plan has the same provisions as Medicare Part D, which means that it also includes a Coverage Gap.  The employer also charges a monthly premium which includes both the drug as well as the medical plan.  In combination with each other, the problem here is that the total cost of the additional amounts charged on a monthly basis, on top of the Part B deductible, begins at $160 a month. In this particular case, the medical coverage is no better than what exists in the Medigap market. To summarize, the coverage is no better, AND the price is higher. It is both more expensive, and provides fewer benefits. Nevertheless, retirees stay with this disadvantageous plan. It is incredible, but true.  This Happens. — 87 —

This Happens: A Global, Thriving Company Often times the reason an employer-sponsored retiree benefit plan may seem cheaper is due to the fact that the employer has put in money from its own funds in order to keep the prices low, to the benefit of its retirees. However, the employer may not be under the obligation to do so, and it can discontinue this type of subsidy if the funds that it has reserved for this purpose have been depleted. To make matters worse, legacy collective bargaining agreements, due to mergers and acquisitions, have restricted companies from renegotiating costly retiree health benefit plans. If this is the case, premiums may increase substantially. In fact, you can look in financial statements, or in the small print of the Summary of Benefits you have been given. A description of your summary of benefits may well describe a situation where the company can choose to discontinue the subsidy and increases are passed to the retiree. The net effect of this type of employer-sponsored retiree group plan is that the benefits are no better than that that exists in the private market, and the costs may be no better, and in certain cases can be more expensive than insurance that exists in the private market. This situation is real and many persons who have been dedicated employees to a particular employer for a long period of time may be disappointed. But given the pressures on treasury departments of large corporations, this can easily be the case.  This Happens.  Medicare-Eligible Retiree & Non-Medicare-Eligible Spouse There are certain situations where you will need to stay with your employer-sponsored group plan, even if it is more expensive, and even if your cost-sharing terms are worse than is available under a Medicare Advantage or Medigap plan. The primary situation is when the retiree is married to a non-Medicare eligible person. Most (the large majority) group plans do not allow a retiree to disenroll and keep the spouse on the employer-sponsored plan.  — 88 —


If that is the case, then the question is going to be whether or not the spouse is eligible for private health insurance. Under the PPACA, the spouse is always eligible for private health insurance under a life qualifying event (LQE), so the question will be whether or not this makes financial sense. 2018 Update. As of this writing, the individual mandate has been repealed. It adds a simpler path for married couples. A Medicare-eligible person can retire, and the spouse can choose to not purchase health insurance, or buy a non-compliant plan (like cancer/stroke/heart attack indemnity plan), or pass entirely.That is the choice of the household. It will most likely be the case that the spouse can obtain health insurance at a cheaper rate than the price being charged by the employer. The reason for this is that a spouse is charged more than the employee in group plans. It works this way to prevent people staying in their jobs simply to obtain health insurance for his/her spouse. When You Retire If you retire, then you have eight months to enroll in Part B without penalty. You can also accept COBRA coverage if your employer coverage ends. This has been described in Chapter 1. That doesn’t mean that you should delay, it only means that you can. In fact, there are many reasons that an employer-provided retiree health insurance plan can be inferior to the private market. First, you must understand that insurance companies themselves are not interested in providing group plans for persons who are Medicare eligible. Professionals, (like me) who arrange employer-sponsored health insurance plans, can observe the pricing for people who are Medicare eligible, and it is much more expensive for those people who older than 65 to retain their existing group plans than to have an individual Medicare plan. There are many exceptions to this, and employers are addressing this via private exchanges, and offering retirees private market plans through these exchanges. Second, employers cannot bear the additional and ever-rising costs associated with retiree health insurance.  Employers understand that the — 89 —

Medicare system is fundamentally going to be challenged over time, and employers are, in general, in no position to pay the rising costs, with no end in sight. This is particularly true for those companies that have downsized significantly, and whose number of retirees is larger than the number of active employees. Increasing life expectancy has only made the situation more drastic from the employer’s point of view.  When you add up these concerns, then it is no wonder that the cost sharing terms of employer-sponsored plans are eroding.  The degree at which they are changing differs widely among employers, but there is little doubt that this is occurring. The financial impact to employers is enormous: employers’ viability can be threatened by the cost of retiree benefits. Spouses of Retirees Cannot Delay If you have been covered under your spouse, who is retired, and you turn 65 years old, then your Initial Election Period ends at the end of the third month following your 65th birthday. You cannot delay enrollment in Medicare Part B if you are the spouse of a retiree. You can only delay enrollment in Medicare Part B if you are the spouse of an active employee. Admittedly, this is complicated, but this point must be understood in order to avoid late enrollment penalties. Pay Careful Attention to Enrollment Issues Warning on Employer-Sponsored Enrollment Calendar Special care is required regarding the election periods when an employer-sponsored group plan is involved.  The reason is that employer-sponsored group plans frequently have enrollment periods which are different from Medicare. For example, many large employer-sponsored group plans have enrollment periods that end after Medicare’s Annual Election Period (AEP, October 15 – December 7). That does not mean that the Medicare Annual Election Period has changed. It effectively shortens the election period for these households. — 90 —


Procrastinators have made, are making, and will make, the error of waiting until the last moment before deciding upon the right configuration of benefits (group vs Medicare, etc). If you wait too long, the selection can be made for you. Worse yet, both the Annual Election Period and the employer-sponsored group plan enrollment period end, and you are left with original Medicare.  Be careful. Check the Medicare Enrollment Requirement The saying goes, “The devil is in the details.”  This old cliché exists for a reason. Here is a prime example of why. In most employer-sponsored retiree group plans, you will have to pay for your Medicare Part B premium which is the $134.00 premium a month for 2018. You must check this yourself, because that will greatly determine whether or not it is a good idea to continue on with your employee group plan.  Do not assume anything: there are many cases when the Human Resources department does not inform employees/retirees whether they are required to enroll in Medicare Part B.  If your employer-sponsored plan requires you to enroll in Medicare Part B, and you do not, then the monthly premiums that you pay for your employer-sponsored plan will most likely be entirely worthless. That is because Medicare is the primary insurer, and the group plan is the secondary insurer. This Happens.  An employee, currently 67 years old, is in excellent health when he becomes eligible for Medicare Part B at 65 years old. He doesn’t read the employee benefits package he has received, so he doesn’t enroll in Medicare Part B. Now, at 67 years old, he requires extensive medical attention. He finds out that his retiree benefits require enrollment in Medicare Part B, which he has not elected. His retiree benefits are null and void, premiums have been deducted from his pension already, he will need to enroll in Medicare Part B, and will have a penalty that never expires. This Happens. — 91 —

It is very important to know the cost sharing arrangement of your retiree health plan. You have received a book every year, most likely one of which is a Summary of Benefits. It will tell you the schedule of the deductibles, coinsurance, as well as copayments under different medical situations.  Special Note: If an employee retires, there is a very difficult situation if the spouse is older than 65. If that spouse had relied solely on the retired employee’s healthcare benefits and presumed that he/she was “all set,”, then the spouse would have to pay the Part B late enrollment penalty if the retiree health benefits did not require enrollment in Part B. If the employee is active, however, it is different. The spouse of an active employee may not be required to enroll in Medicare Part B, and may not be subject to the Part B late enrollment penalty. That said, given the changing landscape of retiree benefits, the safest path to take: double check the Medicare enrollment requirements for both the employee and spouse, and confirm the conclusion by finding the written language that confirms your conclusion. Word of mouth won’t be adequate, and the one that will pay the consequences of the misinformation? This is a very peculiar situation because in most cases, retired employees and their spouses are required to enroll in Medicare Part B if they are eligible, then you must enroll in Medicare Part B when you first become eligible. Examine Cost Sharing Terms Carefully Check the Premium The easiest, and first, step is to check the total premium that will be deducted from your pension plan check. In addition to knowing the Medicare Part B enrollment rules, you also need to know the group plan’s enrollment rules. Can you cancel at any time during the year, or are you required to enroll for the entire calendar year?  Can you change your mind, and when? Every employer has a different combination. There is no way to generalize. — 92 —


Check the Cost-Sharing Terms This is also easy. Employer-sponsored plans frequently charge a premium that is lower than the private market. This can seem attractive. However, you need to be careful, because the cost-sharing terms are frequently weaker. When you add up the out-of-pocket costs if you require medical care, then the overall costs of employer-sponsored plans can be weaker than the private market. The key things to focus on are the cost of office visits, emergency room costs, and annual deductible. You must understand how much you will pay if you are admitted to the hospital. Is this an annual amount, or is it an amount per benefit period? Finally, is there a maximum amount, above which the employer-sponsored plan pays 100%? Lastly, you can check to see if the retiree group plan will cover the Part B Excess defined earlier in this book. Most likely, the Medicare Excess is not covered at all under retiree group health insurance plans. One additional point: some group retiree plans have different copay schedules for office visits. It is a trend for retiree group plans to charge different rates for specialists, and some retiree group plans do not cover specialist visits at all. That means urologists for men, and gynecologists for women. It would be wise to check this carefully. Medicare Advantage is inconsistent with respect to this.  Medigap does not distinguish ($20 per office visit). But in many cases, group plans do. This can be a hidden out-of-pocket cost for group retirees (and their spouses). Note that you are entitled to an annual preventative care visit, in accordance with the Patient Protection and Affordable Care Act (PPACA). You should not be charged for this if you have Medicare Part B. Prescription Coverage Again, this is an entirely mixed bag. Every company will have their own plan with respect to prescriptions. You can most likely see that there is a copay schedule for generic and non-generic prescriptions. You should check to see if there is an annual deductible. — 93 —

You should find out if there is a Coverage Gap (“donut hole”). It is frequently the case that employer-provided plans do not have a Coverage Gap, but there is no guarantee that employer-provided plans eliminate the Coverage Gap. Further it is not always the case that employer-provided group prescription benefits are superior to prescription benefits offered within Medicare Advantage or in Medicare Part D. Since employer-provided plans do not have the competitive nature of the standalone Part D market as a whole, the copay and coinsurance schedule of an employer-provided plan can result in higher prescription drug costs than a standalone Part D plan that is available in the market. Do not assume that the group plan eliminates the donut hole for the Medicare-eligible. Some employer-sponsored plans have no Coverage Gap, and some do. That is at the discretion of the employer. If Your Employer Cancels Retiree Health Benefits It can be the case that an employer simply stops providing retiree health benefits. This has happened, this is happening (and being actively considered), and it will happen.  There can be little or no warning in advance. You probably know someone that has received this type of notification in the mail.   First, do not panic. You will be allowed to select a Medicare Advantage or a Medigap plan, along with a Medicare Part D plan, if necessary, under a Special Election Period (SEP).  In the previous section above, this is explained. From the date of discontinuation, you will have 63 days to select a new plan, without incurring a penalty if you want to select a Medigap policy. You need to be careful here because the rules are different if you want to select a Medicare Advantage plan. Second, you will need to keep the copy of the notice of cancellation from your employer and/or the insurance company that provided the employer-sponsored health benefits. In your Summary of Benefits, or in a separate document, there will be a Letter of Creditable Coverage. This will be necessary to use as evidence of your eligibility for a Special Enrollment Period. — 94 —


Third, you will most likely be directed by your employer to a particular plan or company as a substitute. You should not sign up on the spot, without checking the market first.  Remember that the sponsor of the meeting, the employer, is the same one that is discontinuing your coverage. The employer is doing what is best for its constituents, its shareholders/owners. You should do the same, and act for yourself, since you have a constituency as well: yourself, your family, and those that care about you. This section intentionally left blank.

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This Happens. Globally recognized company has declared bankruptcy during the early 2000s. Salaried employees, not protected from bankruptcy, have employee benefits slowly, but inevitably, taken from them. Finally, retiree health benefits are next.  Medicare-eligible white-collar workers are given a stipend as a substitute for health benefits, and they attend coordinated employee information sessions. Many employees accept the recommendations, and enroll in the Medigap policy presented during these sessions.  Now, that insurance company faces severe claims over time, and rates have gone up multiple times a year. Those with preexisting conditions are largely ineligible from switching to other carriers (insurance companies), because the open enrollment period is over, and the Special Election Period has also expired.  The retiree now can choose to either accept rapidly rising premiums, or a plan with weaker coverage. This Happens. You can freely select any MA or MAPD during this period. You can freely select any Prescription Drug Plan during this period. However, you may or may not be able to select a specific Medigap plan. There will be some selection allowed, but it may be the case that all insurance companies do not offer all plans to you. Therefore, if you have a specific plan in mind, then you will need to check around.  Do not accept information from outside sources if they tell you it is completely impossible to purchase a particular plan. Different companies have made different business decisions regarding this.  Insurance companies have differing policies when applicants attempt to enroll in Medigap. This is an important, overlooked fact. Some people just think that they will deal with the issue if the employer cancels coverage, or if the cost sharing arrangement dramatically changes. Depending upon the insurance company, that specific option may not be available to you at that time.  — 96 —


You may then look back, with regret, for not taking matters into your own hands, especially if the financial aspects were roughly equal. And you know what?  You could have done something about it then, and now you will face an uncertain health and financial outcome, as a result of not addressing this issue when it was within your control.  Employer-Sponsored Medicare Advantage When you become Medicare eligible, it is vital to know what plan the employer is providing to you. It can be the case that the employer is enrolling you in a Medicare Advantage plan whose network may not be the same as the plan you were using prior to Medicare eligibility.  The confusing part of this is that the Medicare plan that you were given as a retiree can be different fundamentally from the HMO or PPO that you have been given as an active employee in your pre-Medicare days. That means that the list of providers may or may not be the same providers that covered you before you were Medicare eligible.  This is a very important point, and as a result you need to consider carefully what you are actually doing, and what you were actually electing. If you travel out of the state frequently, or for many months during the year, you can end up finding out that your total medical costs, meaning your premiums plus out-of-pocket expenses, may exceed other arrangements which could be done in the private market, where there may be no such restrictions. That will entirely depend on which plans are made available by your employer. Dental, Vision, and Other “Benefits” Some retirees believe that there are other types of additional benefits as part of the employer-sponsored plan which are very important, such as dental and vision insurance. However, the reality is that dental and vision insurance is often times limited by a maximum amount of benefits that can be received in a calendar year. These types of insurance are limited; benefits are very low, unless you use the entire maximum benefit every — 97 —

year. It is very frequently the case that you will be able to find the dental and vision coverage which is at least as good as the employer-sponsored plan. For those people who require extensive dental work, for example, you will find that the annual benefit amounts can be somewhere in the $1000$1500 range, per year, per person.  As a result, the amount of benefit actually received by the retiree and their family members is very limited. Private-market vision and dental can frequently be obtained for cheaper prices than is being charged by employer-sponsored plans. It is simply more convenient for you to select the “package deal.” It is costing you money that you would otherwise use for better health insurance or prescription drug coverage. What Employers Can Do This topic is too broad to cover in one section. It will be the topic of another book by itself. However, there are some guidelines to follow. First, both employers and employees can be better off if employers create incentives for employees to elect a Medicare plan or Medigap plan independently. This may require negotiation of existing contracts. Nevertheless, the savings will be well worth it.  Second, the employer-sponsored group plan should provide for those whose families require group coverage, because there will be cases in which family members cannot otherwise obtain health insurance at a reasonable price.  Third, health savings accounts (HSA) are a good way to incentivize employees to maintain their health, and to lower costs. They can be established so that if people need to defer election of Medicare Part B, then that person may be able to save extra money, on a pre-tax basis, which can be used to pay for Medicare Part B premiums when he/she enrolls in Medicare Part B. One of the group health plan alternatives should include a High Deductible Health Plan, which works alongside with Health Savings Accounts. — 98 —


Objections that employees or retirees may raise can be solved by one of three suggestions. Sometimes, collective bargaining tensions prevent reasonableness by all parties. However, if employer and employees work together, the difference in pricing between group plans and Medicare plans is so large that the cost savings are worth the effort. There are many instances, however, when the rational solution remains elusive. Employer/employee relations become strained, reasonableness is not considered, and both sides suffer. These days, this can be easily found in the case of municipalities, where fiscal concerns are clashing with legacy collective bargaining agreements. This Happens. Unionized employees and their employer, a local government under financial duress, are renegotiating their collective bargaining agreement.  The agreement stipulates that retirees are entitled to identical coverage that they received when they were active employees.  Now, Medicare Advantage and Medigap are superior in both price and coverage to the benefits they were receiving when these retirees were active employees.  However, the union and management cannot find a middle ground, and the active employees go on strike. This Happens. For employers, the cost savings can be large enough to ensure the viability of a business/company. For employees, not only are the prices lower, but the coverage is often superior to that offered by a group plan. Perhaps both sides can all agree on one thing: an employer choosing to close his/ her business due to the high cost of health insurance is the least favorable outcome. Those are the stakes. As such, everything should be explored fully. If you are an employer, and you have Medicare-eligible employees or retirees, then you should actively attempt to find a better solution. It is very likely that you will be successful in finding a reasonable, workable solution. — 99 —

One solution, a very good one, is being adopted by a few selected large employers. They are adopting Medigap High-Deductible Plan F for everyone that is Medicare eligible, and allowing their retirees to pay for additional amounts of insurance. As a reminder, High-Deductible Plan F is a Medigap policy that has a large deductible ($2,240.00 in 2018), and the Medicare beneficiary pays it. Thereafter, there are no further copays or deductibles. Certain clever employers are providing a cost sharing agreement of this $2,240.00 with retirees. For example, the retiree pays $50 per month but then only has to pay a maximum of $1000.0 per year, and the employer covers $1,200.00. Now, the High-Deductible Plan F is satisfied. If claims are above this, then the Medigap High-Deductible Plan F pays for the remainder. This is entirely possible and an excellent solution for both employers and Medicare eligible retirees. Difficult times require creativity, and this is indeed creative. Obamacare and Employer-Sponsored Plans There are very important implications for married couples who have been or are currently covered by employer-sponsored healthcare benefits. If you are an active employee, and as an employee, you receive health insurance benefits, your spouse may be able to elect to receive benefits from the group plan, and can also choose to opt out. While the spouse can choose another health insurance plan, the spouse cannot apply for governmental assistance, commonly known as Medicaid expansion. The key point: you and your spouse can do as you wish, but you cannot receive Medicaid expansion assistance for premiums paid. If you are retired, however, then it is slightly different. A retired employee can opt out, and the spouse can also opt out. In addition, the spouse can apply for premium assistance under Medicaid expansion by applying for private health insurance in your state’s insurance exchange. Acceptance would depend on household income stipulations embedded in the PPACA, and the state in which you live.

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When compared to the situation a married couple faced before the PPACA was enacted, a spouse can have a wider set of options under the PPACA. For example, a spouse with pre-existing medical conditions cannot be denied coverage. There will also be no waiting period for receiving health benefits from the insurance carrier. A wider set of choices, and potentially, the ability to receive governmental assistance on the premium: those are the results of the PPACA for spouses of Medicare beneficiaries. The issue is that the private health insurance market has weakened, premiums are much higher, and the networks have become narrower for Federally-facilitated marketplace ( plans. Recent political developments include the elimination of the individual mandate entirely. An uncovered spouse could choose to remain uncovered, or covered by a non-compliant plan (hospital indemnity, cancer, stroke, heart attack policies exist). The resulting political uncertainty will result in very different consequences for different households. An expert should be able to help you to carefully consider the wide range of options available.

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 SPECIAL GROUPS Truths and Myths Truth: The Veterans Administration recommends that veterans enroll in Medicare Part B when turning 65 years old. Myth: Retiree “groups” always provide benefits that are superior to Medigap and privately-purchased Medicare Advantage plans. Veterans Administration (VA) Veterans face complicated choices. VA benefits, including retiree health benefits, is a very complicated matter. There are benefits as well as drawbacks to the VA medical system for those who are eligible for Medicare. The Department of Veterans Affairs recommends that veterans enroll in Medicare Part A and Part B. Among the reasons is that the level of funding of VA benefits is not guaranteed in the future. The most recent episodes of long waiting lists for veterans to receive healthcare can be added to those reasons. Strictly speaking, veterans that receive medical care at VA medical centers (or those facilities that are contracted to provide VA service) are not required to enroll in Medicare Part B. Further, veterans that receive prescriptions from the VA are not required to enroll in Medicare Part D. As many know, prescription drug benefits through the VA are frequently superior to Medicare Part D due to the very low copays associated with the VA. That said, some veterans find the process of refilling prescriptions through the VA to be difficult (too — 103 —

far away, need to see VA primary care physician). There is no conflict between having both VA prescription drug benefits and a Medicare Part D plan. The key point is that while veterans can receive health and prescription drug benefits through VA channels, late enrollment penalties continue to apply, if you enroll for Medicare Part B and/or Part D in the future. Tricare For Life (TFL) For career military retirees, the most comprehensive set of benefits is called Tricare For Life (TFL), for those persons who have been in the military as a career; they are entitled to a full set of benefits. In addition, it has been the case that those people who suffered a disability that is directly linked to active combat may also be granted TFL. The most prevalent case is when someone has a documented case of exposure to Agent Orange, and has suffered from a medical situation that has been linked to that exposure.  In other cases, it is not granted.  The best way to find out if you are entitled to TFL is to contact the Veterans Administration. This section presumes that a veteran knows how to register in the Defense Enrollment Eligibility Reporting System, otherwise known as DEERS ( or the Department of Veteran Affairs website (http://  Tricare For Life requires enrollment in both Medicare Part A and Part B. To use your Tricare For Life, your military identification will identify you as a TFL beneficiary. TFL beneficiaries may have some small co-pays for prescriptions and will also have complete medical coverage.  That medical coverage is based on the military set of approved procedures and treatments.  Please note: the list of approved procedures and treatments is NOT identical to Medicare-approved procedures and treatments. They are separate, but clearly, there is substantial overlap. A particular treatment belonging to TFL’s approved therapies and not belonging to Medicare’s approved treatments is very rare, but there are instances in which this peculiar situation does exist.  — 104 —


There are public policy questions regarding TFL. You may be aware of this; Congress has debated whether or not TFL should remain free, and/or whether or not TFL should be administered by the private sector. Those questions remain open, and are beyond the scope of this book. Non-Tricare Veterans Benefits If you are not entitled to TFL, you still may qualify for VA benefits. You will need to individually enroll.  You can do this online by visiting this website:  For those that qualify, an individualized set of benefits is awarded according to many separate tiers. The VA will determine your tier. That is beyond the scope of this book. Some aspects are shared in common by most, if not all, eight tiers. Here are some, but not all of those aspects. You will be assigned a primary care provider and will need to attend VA facilities, which exist nationwide. For some, this works well. For others, it isn’t practical, because VA facilities are not nearby. VA benefits generally provide prescriptions benefits at very reasonable costs, frequently superior to Medicare Part D.  The extent of the benefits that you receive can be subject to review because your status can change. From this perspective, one should be careful. This Happens. Eligibility and cost sharing is subject to review by the VA.  If you have been receiving VA benefits in the past, it may not necessarily be the case in the future. If your eligibility is examined, the opposite can also occur. It has been the case that a person that was previously receiving limited benefits from the VA has been stripped of these benefits, which left the Medicare-eligible beneficiary in a position in which he had to find both health insurance and prescription insurance. This Happens. — 105 —

If you do not qualify for TFL, and yet are eligible to receive prescriptions through VA services, there are a couple of things to know. The first is that insulin is usually not well covered by VA benefits. This may be a reason to purchase the cheapest possible MAPD or a stand-alone prescription plan (Medicare Part D). The second is that if you solely use VA medical facilities and do not require a prescription drug plan, then you have a special situation. Earlier, the idea of “additional benefits” was described as part of certain MA and/or MAPD plans. An easy example would be that there may be discounts for smoking cessation programs.  Within MA, there are certain plans that have zero ($0) premium. They are without prescription benefits, which is fine since you may receive your prescriptions through the VA.  A VA beneficiary is entitled to enroll in a Medicare Advantage plan with no premium, use the additional benefits, and use VA facilities for medical services and VA pharmacies for prescriptions. As of this writing, there is no conflict in this setup. Additionally, you can use the MA card (although there will be cost sharing in accordance with the MA or MAPD plan) if you strongly prefer to not use VA facilities. If you have an “emergency” that is not ruled to qualify as an emergency, then you would have a lower out-of-pocket cost by using your Medicare Advantage plan. This Happens. A VA beneficiary goes to the emergency room at local hospital, which is not a VA hospital, with the belief that he is very ill. It turns out to be nothing. He is required to pay the full cost of the services administered at the emergency room. The only portion that is reimbursed is the ambulance transfer from the non-VA facility to the VA facility, and then only if coordinated by the VA facility. This Happens. If you do qualify for TFL, then you can also benefit from this same arrangement.  You can enroll in a Medicare Advantage plan with no premi— 106 —


um, and choose the plan that has “additional benefits” that accompany the MA or MAPD. Depending on the plan, that can mean that you can take advantage of dental, vision, and other services, such as chiropractic services. You may wonder, “How does this work?” or “How is this possible?” The reason is that under MA or MAPD, the Medicare system hands the processing of claims, the accounting of claims, etc., to the private insurance company. The Medicare system pays the private insurance company a lot of money to take the place of CMS. The individual carrier uses some of this money in order to pay for the extra benefits, under the idea that these extra benefits will result in better health, and therefore lower medical claims. Federal Employee Health Benefits (FEHB) Program Eligible persons include both active employees and retirees from the U.S. Federal Government, including U.S. Postal Service employees and retirees.  If you are Medicare-eligible, then you have a couple of difficult choices, and it does depend on whether or not you are federal government employee/retiree or a Postal Service employee/retiree. Enrollment in the FEHB runs on a different calendar than the Medicare Annual Election Period. Federal government employees/retirees have comprehensive health and prescription coverage. There is no donut hole in the FEHB program. In addition, persons under FEHB can elect an MA/MAPD in addition to their existing benefits, and there is no conflict. In short, it is the same as if a person is entitled to Tricare For Life as described earlier. Even if you stay with the FEHB, you can subscribe to a zero premium MA/MAPD, and reap the additional benefits that may be offered with that MA/MAPD plan. That’s correct: there are some MA plans with no premium. For normal enrollees, FEHB does present an issue, however. That issue is the price.  For federal government employees, the most comprehensive plan is expensive when compared to the private market for similar — 107 —

coverage, except for the donut hole. The bottom line is that if you are in excellent health, then it might be prudent to choose a more affordable plan with little or no change in coverage.  Postal Service employees face a different set of circumstances. As of the current writing, the premium charged to Postal Service employees is far lower, and cannot be replicated in the private market. For former postal employees, the zero premium MA/MAPD plan, in conjunction with FEHB Plan benefits, will result in the lowest cost, along with the additional benefits that can sometimes be offered with MA/MAPD plans.  If you are married, spouses of Postal Service employees need to be considered.  Spouses of postal services employees are charged at different rates from the employee.  If the spouse of a Postal Employee is Medicare-eligible, then all of the statements regarding group insurance apply. That may depend upon the Part D Coverage Gap (“donut hole”), i.e. if the spouse of a Postal Service employee/retiree requires large amounts of prescriptions, then staying inside the FEHB Plan may be best. This Happens. An active postal service employee is married to a Medicare-eligible spouse. The spouse elects to not enroll in Medicare Part B when she turned 65 years old. However, over the course of the next year, she develops a medical situation, and her husband retires before turning 65 years old. The human resources representative informs the employee that he and his spouse will no longer be eligible for FEHB benefits. The spouse enrolls in Medicare under a Special Election Period (SEP). However, the issue is the she cannot choose the Medigap plan that would have been cheapest, and must choose the next best alternative, when she could have selected her initial choice if she had enrolled in Medicare when she was first eligible. This Happens.

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State and Local Government Employees Detroit, MI and Stockton, CA, along with countless other locations, face very high legacy obligations, which can result in the bankruptcy of the entire municipality. This can create great uncertainty and turmoil among retirees, and current employees will be required to think carefully, rather than blindly assume that retiree benefits are guaranteed. State government employees may or may not be required to enroll in Medicare Part B when initially eligible. However, it is highly likely that you will be required to enroll in Medicare Part B. You will need to check that, and most states describe how Medicare will work with that state’s health plan.  Steps to take. First, you will need to find out if Medicare Part B enrollment is required. Second, you will need to know how Medicare will work with your employer plan. It is typically the case that Medicare will be the primary provider, and your state’s plan will be secondary because you will be selecting a group Medicare Advantage plan. Third, if Medicare is primary and your state’s plan is secondary, then you will need to find out what your state’s plan will cover, above and beyond what original Medicare covers. Most plans do not specify whether or not the Part B Excess charge is paid by the government-sponsored plan. That is another way of saying, “No, but confirm this by yourselves.” Finally, it would be a good idea to find out if you are able to cancel your government-sponsored plan, and then re-enter at a later date. Again, it is unlikely this is the case, but you should know this before making a decision. Local government contracts are usually quite different. Since there can be collective bargaining agreements for certain workers (sanitation, maintenance, transportation), it can be very delicate. Here are some important guidelines.  First, if your local government compensates you for “opting out,” paying you cash in exchange for you canceling your group plan, then you should examine this carefully. It may well be that this is worth it. If your spouse is not Medicare-eligible, then he/she can enroll in an individual plan, — 109 —

without concern over pre-existing conditions, under the PPACA. Second, the terms and conditions of your benefits will vary widely from location to location. That will be the single biggest factor in deciding whether or not you should keep your retiree benefits plan. In the best cases, retiree benefits are continuing without any changes. In other cases, bankruptcy has been declared, and governments have tried to discontinue retiree health benefits entirely, as has been the case in Stockton, California (Los Angeles Times, 12 July 2012). If you stay in your group plan, then the price that will be deducted from your paycheck or pension may be too high. This is especially the case when you figure in the out-ofpocket expenses in conjunction with your group plan, and compare it to a Medicare Advantage or Medigap plan.  Third, you need to explore whether or not you can opt out of your medical and prescription coverage, and retain your dental and vision coverage. You should consider whether or not the price that you are charged for this dental and vision coverage is worth the price that you pay, when compared to the private market (see “Dental, Vision, and Other ‘Benefits’” from Chapter 7).  Educators A special type of employee is a public school educator. Faced with budgetary problems, state governments are being forced to change the benefits packages of both active and retired teachers. For example, in the State of Michigan, a new motion has been passed to enact this. The result of this is that retired teachers have been faced with a changing landscape regarding their retiree health benefits.  In many cases, new teachers will face a future without retiree health benefits.  For currently retired teachers, higher premiums may result.  The point of this is that teachers may need to look at prices, because the price in the private market may soon approach the retiree benefits package’s price. The nature of the group has changed, but the message is the same: educators will not be able to simply presume that their retiree benefits package is the best that they can afford. — 110 —


Unions “If your friend jumped off a bridge, would you follow him/her?” –Parent to child “I will stay with my group plan. My buddies say that everything has worked out OK.” -The same person commenting about his group benefits under Medicare In coffee shops around the country, you can hear this conversation. That is guaranteed.  This section addresses employees and retirees that are members of unions governed by collective bargaining agreements. This section does not include hourly UAW members, who are covered by the Retiree Benefits Trust, a VEBA trust. Unfortunately, the bottom line is you will face many of the same things that other Medicare-eligible employees face. Most times, union contracts heavily favor active employees. Union officials have motivations to promote group plans. One primary reason is that group pricing may be dependent upon the number of enrollees in the retiree group plan, or the percentage of enrollment. While that may be admirable for the group as a whole, the problem is that it may not be good for the individual, i.e. you.  What this means is that if you have a medical situation, you are back to my base case. You need to fend for yourself. Examine for yourself, investigate for yourself, and ultimately, decide for yourself. Unless the collective bargaining agreement has closed down the Medicare Part D Coverage Gap, and you or your spouse require medications that exceed Medicare Part D coverage, the almost-inevitable conclusion will be that an individual plan, whether that is a Medicare Advantage or a Medigap policy along with a standalone prescription drug plan, will be more cost effective. The recommendations made here may seem controversial, because as part of a union, you probably have friends and colleagues who are roughly your age.  Those friends or colleagues have gone through the Medicare system. The main piece of advice to leave with you is simple: your individual situation can be different from your friend’s, and don’t — 111 —

presume that just because things have “worked out well,” that it fits your individual situation. This may seem self-evident, but this happens very frequently. In other words, just because your friend jumped off a bridge doesn’t necessarily mean that it is a good idea for you. Finding out the information for yourself, and making an informed, intentional choice is the best path. Life may or may not work out as you envisioned; hopefully, it is even better.  However, the intent of this book is to avoid taking risks that you did not intend. That is not the same thing as you choosing the risks that you are willing to accept, and avoiding those that you do not want to accept.  You may have financial reasons for choosing a particular plan. You may have private motivations. It isn’t the goal of this book to cast judgment on your motivations. However, using the information presented here, you can accept risks with full, or nearly full, information. Disabled and Employer-Sponsored Plan If you are entitled to Medicare due to non-ESRD disability, then Medicare is first if you are not covered by a large employer group plan. In this case, a “large employer group plan” is defined as one that covers at least 100 employees. If you are covered by an employer-sponsored plan that does not cover at least 100 employees, the Medicare is first, and the group plan is second. ESRD and COBRA or Employer-Sponsored Plan If you have ESRD and any employer-sponsored plan, then the employer-sponsored plan is the primary source of insurance for the first 30 months, and Medicare is the secondary payer. After 30 months, Medicare is primary, and the employer-sponsored plan is secondary. If you have ESRD and COBRA, then COBRA is the primary payer for the first 30 months, and Medicare is secondary. It is important to note — 112 —


that the private market (Medicare Advantage or Medigap) are very likely to be superior to a COBRA plan, because the cost and/or coverage are likely to be superior. As earlier, COBRA usually is another way of saying “overpriced for what you get,” and unless it is being paid for by an outside source, it is usually not a good idea to remain under COBRA coverage. In Chapter 1, you should refer to “COBRA Works for 8 Months Only.” Hospital (and Other Healthcare) Employees For personnel who work at hospitals, or home healthcare services, it is sad and disappointing to report that the health benefits available to retirees of these organizations can be no better than your average group employer in an industry unrelated to health. In fact, healthcare organizations frequently discontinue health insurance entirely once a person becomes inactive.  In hospitals, you may know that active employees can work beyond the age of 65. Those persons are generally covered. The issue for you is that if you are Medicare eligible, you must check your benefits very carefully when you turn 65. Different organizations offer a wide range of alternatives. You may need to sign up for Medicare Part B, or you may not be required to sign up for Part B.  You may have your choice. You can read the section titled “Married, Group coverage, and Medicare: Who Pays First? Good Luck.” You will need to refer to it again. Healthcare providers vary widely in size, so you will need to carefully read to identify your situation.  One special provision can accompany group coverage for hospital employees:  prescription drugs are often offered to hospital employees at substantial discounts. These discounts, if combined with the lack of Coverage Gap, can represent substantially lower out-of-pocket prescription drug expenses. Small Business Owners This section is geared to the small business owner.  At the end of Chapter 7, there is a section called “What Employers Can Do.” The issues and — 113 —

challenges stated in that section are ones that should be very familiar to the small business owner. In addition to the issues mentioned in that chapter, there are additional challenges that need to be faced, since the business owner is the main stakeholder, there may be legal, tax, and accounting issues, all of which are ultimately the responsibility of the owner. Depending upon the size and scope of the business, you may require an outside advisor. From a health insurance perspective, a Medicare-eligible small business owner should keep a few things in mind. The new regulations that index your Medicare Part B and Part D premiums to income are complicating matters for high-income earners. Since Medicare Part B and Part D are indexed to your annual income, it may be that the cost of the premiums is as high as your small business group health insurance premium.  For example, if you make over $214,000 a year, then your monthly Part B premium will be $428.60 a month. When you add a Medigap plan, and a Part D premium, your health insurance total premium will exceed $700 a month. Depending on the state, employer plans may be established which include tax benefits for funds used to pay for premiums and out-of-pocket expenses. While it may be very possible to find a more economical configuration under a small-employer group plan, caution is required. That is because Medigap Plan F has no cost-sharing provisions; the premiums are your entire medical cost (except for prescriptions).  Remember that while you will be able to opt out of your group plan and into Medicare, that doesn’t mean that Medicare will be in its current state, if/when you choose that path.  As mentioned earlier, there is speculation that Medigap Plan F may be subject to fundamental change (this prediction has occurred: Medigap Plan C and Medigap Plan F will no longer be available, beginning in 2020). There may be tax implications to your selection, depending upon the legal structure of your business.  You may be taking a business deduction for the cost of health insurance.  You should receive tax or financial counseling before deciding on this important matter.  In this particular case, it — 114 —


may be wise to consult your tax advisor. One word of warning: some insurance companies will not be able to sell certain Medigap plans if you are opting out of group plans. This is above and beyond the “normal” restrictions that occur when a person qualifies for a Special Enrollment Period. Professional “Associations” Doctors, lawyers, accountants, dentists, etc all have professional affiliations of some sort. Within these, there is a decidedly mixed bag. While some organizations are based on a state level, some are national in scope and scale. There can be associations within a profession, like oncologists within physicians. If this is you, you may have been too busy to consider the outside market. You need to consider whether or not the insurance company that sends you the “package deal” is doing so as a commercial endeavor. This Happens. A professional has been privately insured through his private practice, and continues to work through his 60s. He is eligible and enrolls in Medicare Part A and Part B. In addition, his professional organization offers private health insurance (at group rates), which is more than $300 a month more expensive than Medigap Plan F and a stand-alone prescription drug plan (Medicare Part D). It does so without offering or sending out the professional any information regarding Medigap or the cost sharing arrangement that is available under Medigap. The professional eventually is informed about Medigap and correctly makes the change to Medigap and Part D. It has cost him more than $10,000 in excess premium for coverage that is no better than Medigap and a stand-alone prescription drug plan. This Happens.

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There is no sense in pointing fingers, and blaming this party or that party. At this point, $10,000 is gone. It doesn’t matter how rich you are, $10,000 is a lot of money that could’ve been otherwise saved or spent (that may be the least controversial statement in this book). Maximize Your Medicare is written so you can do something for yourself that others will not. Even professional associations, created to defend its members, can fall woefully short. Seriously Ill Those who are seriously ill face difficult choices. By seriously ill, I mean that you have a condition that will not improve through time.  Even among those persons, there is a very large difference among the type of illness, and as a result, there are different factors to consider. If you take a lot of medications, then you must choose the best standalone prescription drug plan (Part D) that you can afford.  While the monthly premiums are higher, these plans are more likely to have lower copays for non-generic drugs. In addition, many higher-priced plans will have benefits even inside the Coverage Gap (“donut hole”). Sometimes, patients take a large number of medications, but do not require visits to the physician often. Alzheimer’s patients may, in certain cases, be in a maintenance mode, where relatively few office visits are required.  If that is your situation, then the extra dollar should be used for prescription coverage, and not for medical insurance. If you are choosing a Medicare Advantage plan, you should recognize that the prescription benefits within different MA plans can vary, and that can result in a large difference to you. If you require frequent office visits in order to monitor your situation (for example, Type 1 diabetes), then your situation is slightly different. You will require frequent examinations (eye exam, foot exam) in order to monitor diabetes’ progression. In addition, if the situation spins out of control, then the complications are serious, and can potentially require surgical procedures. If this is the case, then it is my view that you require the most comprehensive medical coverage that you can. For you, the Part — 116 —


B Excess may become an issue, because you will most likely have to visit the doctor often, and in difficult scenarios, you may be charged more than the Medicare-allowed charge. For this reason, either very strong Medicare Advantage (PPO), or the most comprehensive Medigap policy may be best. Taking care of these situations is never easy, and absent a crystal ball to predict the progression of any given situation. However, it is especially important to think of these scenarios in advance, so that you can respond the situation now, and make the best selection with those scenarios in mind. The reason for this is to preserve the maximum number of options in the future. Diabetes There is no easy way to say it: diabetes has reached epidemic proportions in the United States. According the Centers for Disease Control and Prevention (CDC), 25.8 MILLION people in the U.S. have diabetes of some form. Of 10.9 million, aged 65 or older, 26.9% (!!!) had diabetes in 2010. Diabetes is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults in the United States. For people with Type 2 diabetes, medications are available, and they are very inexpensive. Generics used to treat diabetes are among the cheapest in the market. As long as things do not spin out of control, then it is possible to keep your total health care costs down. Type 1 diabetes is treated differently among Medigap carriers. For new applicants, Type 1 diabetes can lead to denial by certain carriers, and acceptance by other carriers. Remember that carriers do have the prerogative to make that determination, and their underwriting rules can change. That said, you may have the regulated right if you were leaving a group plan, a certain set of Medigap plans (A, B, C, F, K, L) would remain as guaranteed-issue for a period of time. For Type 1 diabetes patients, prescriptions coverage is also a complicated — 117 —

matter because of the use of insulin. Regarding insulin, Medicare Part B plays a unique role. Needles used for insulin injections are defined as durable medical equipment covered by Medicare Part A. Nowadays, insulin is dispensed through a pen, which is part of the prescription; the plastic handle itself is part of the prescription. If you are dependent upon insulin, then you will usually reach the Medicare Part D Coverage Gap (“donut hole”). It may be wise to select a Part D plan that has benefits even when in the Coverage Gap. End Stage Renal Disease (ESRD) End Stage Renal Disease (ESRD) patients and Medicare is quite complicated. In addition to the very high cost of dialysis, the interaction of Medicare, group health insurance, Medicare Advantage and Medigap are very complicated. Here are the simple guidelines. First, Medigap is available for ESRD patients during Medigap open enrollment. Second, Medicare Advantage is, generally not available for ESRD patients, unless you are eligible for Medicare before the age of 65. Third, if you or your spouse work, then you should refer to Chapter 7, and read the section called “Married, Group Coverage, and Medicare: Who Pays First?” The point here is that dialysis is going to be required on a consistent basis, with no end (other than transplant). The cost can be enormous over the long run, and it may be wise to divert whatever financial resources are available in order to minimize the out-of-pocket expenses.

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NOTES PAGE ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������

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 RELATED TOPICS Truths and Myths Truth: Medicare is a vital cornerstone of virtually everyone’s retirement savings plan. Truth: Many financial advisers do not understand Medicare, and that leads to you taking unknown financial risks. Myth: Representatives of insurance companies and agents are all equally able to explain Medicare to everyone. Medicare Will Evolve and You Must Adjust Maximize Your Medicare is the only book that makes this central point. The list of challenges facing the Medicare system is long. Headlines, in every single year, since the first edition of this book prove the point. If a last-moment legislative change had not been enacted in November 2015, Medicare Part B premiums would have exceeded $152/month for the 30% of those not protected by the “hold harmless” provision. The introduction of IRRMA allows the CMS to charge high-income earners more for Medicare Part B, and the extra amounts being charged are increasing. Medigap Plan C and Medigap Plan F will be discontinued, beginning in 2020, and for a different reason. It is not the result of the legislative changes in November 2015. Rather, it is result of the Medicare Access and CHIP Reauthorization Act (MACRA), otherwise known as “Permanent doc fix” enacted in Spring, 2015.

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The number of alternatives available to beneficiaries when becoming a Medicare beneficiary is small when compared to investment and retirement planning products. Please re-read the section in Chapter 1, titled “Medicare is Vital to Retirement Planning.” It is not all bad news. One factor than many retirees (and future retirees) overlook: the sellers of these products are continuously innovating. Medicare plan carriers, insurance companies that offer other insurance policies, and securities firms that offer investment products are modifying their policies. They are highly motivated to do so. They are fully aware that current retirees and those that will become retirees over the next two decades will represent the vast majority of savings in the U.S. They are responding by offering many new products which address concerns and needs of our aging population. The challenge is that you are left to put the individual pieces together. An a la carte approach, in which Social Security, Medicare, and retirement savings plans are individually considered, without an overall approach, may expose your household to risks that don’t reveal themselves until it is too late. Health Insurance and Life Insurance Are Related This section is devoted to the interaction between health insurance and life insurance. Health insurance provides coverage for morbidity, which is a state of being ill.  Life insurance provides coverage for mortality. When you apply for life insurance, insurance companies may ask you to sign a release, which allows them to access your private health information (PHI). Based on that, insurance companies will record their decision with something called the MIB Group, Inc’s database. Both life and health insurance companies belong to this member-owned group. If you have applied for life insurance or health insurance in the past, and you have been refused, then this information will be revealed each time you try to apply for insurance in the future.  For those in the Medicare Initial Enrollment Period, this is no issue. This does not affect your ability to select a Medigap plan of your choosing — 122 —


while in the Medigap open enrollment period. Nor does it affect your ability to select or change a Medicare Advantage (Medicare Part C) plan during the Initial Coverage Election Period (ICEP), Annual Election Period (AEP), or any of the Special Election Periods (SEP). However, your private health information may affect your ability to obtain life insurance at the best possible price.  There are many different types of life insurance. Advertisements can be found everywhere: in the mail, on the radio, and on TV. The two types of life insurance that are most predominant are term and whole (permanent) life insurance.  Term life insurance is easy to understand. You pay premiums until a particular expiry date. Once that expiry date passes, you no longer have life insurance. The insurance company may extend the expiry date, at a different price. That price is generally much higher than the one originally paid. There is no cash value established under virtually all term life insurance policies. It is a little-known fact that underwriting (i.e. the approval process) can be more difficult under term life insurance than whole life insurance. Whole life is also easy to understand. You pay premiums, and as long you continue to pay, then the death benefit is paid to the beneficiary that you designate. A cash value is often built, which earns an interest rate that may fluctuate over time, depending on financial markets.   If you stop paying premiums, then there are options usually available to you, ranging from a paid-up option to the redemption of your cash value.  (Note: there can be tax implications to redeeming your cash value, and you should inform yourself of these ramifications beforehand.) Going forward, this book will deal with whole life insurance. The reason for this is that term insurance is more difficult to obtain than whole life, or permanent, insurance.  There is a way to obtain whole life insurance without answering an extensive set of medical questions. You can answer the many fliers that you receive in the mail: they are usually this type of whole life insurance and — 123 —

will be issued without medical questions. The positive aspect of this is that once the policy has been issued (presuming that you have told the truth about yourself ), then it is irrevocable. That means that it remains in place as long as you continue to pay premiums. For this book’s purposes, this will be called “Simplified Issue Whole Life Insurance.” Insurance companies will have a number of different names for this. For those without health issues (disease, recent history of surgeries to address ongoing medical problems), a superior alternative exists.  This type of insurance is usually not available by simply sending in a flyer in the mail. Generally, you will need to contact an insurance company or agency. There will be specific questions to answer. You may find this cumbersome. For the same price, you would be right.  For 30% less a year (at least), however, it is probably well worth the inconvenience. For this book’s purposes, this will be called “Underwritten Whole Life Insurance.”  The best way to get the best price for whole life insurance is to first obtain Simplified Issue Whole Life Insurance. After it has been issued, then apply for Underwritten Whole Life Insurance. You can then cancel your Simplified Issue Whole Life Insurance. If you do this with the help of an agent, then it is possible to get a refund on your initial Simplified Issue Whole Life Insurance policy.  For those without medications, or those without a history of surgical procedures, this is possible. For those with an episode of cancer greater than 10 years ago, this is possible. The standards for approval vary widely, and the prices vary widely. Even though the prices vary, you will be able to find that the market is competitive, and the top carriers’ premiums will be within dollars of each other, per year.  You will need to draw a careful balance between obtaining the best price, without sending too many applications. Remember: the MIB is keeping track of this, to prevent wrongdoing. In addition, insurance companies may ask you whether you are simultaneously applying for multiple insurance policies.

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So why is this explanation given in this book? With age comes weaker health. Weaker health makes life insurance more difficult to obtain. Older age makes life insurance more expensive to obtain. As you consider health insurance options for the remainder of your life, it is an opportune time to consider final expenses. It is a delicate topic. A complete financial plan, whether wealthy or not, includes life insurance, to prevent being a burden on your remaining family. If your mindset includes thinking about health insurance in order to protect your health and minimize costs, then the same reasoning applies to the best approach to life insurance. Get the best protection that you can reasonably afford, before circumstances, whether within your control or beyond it, change for the worse. This is the central recommendation of the book when it comes to health insurance.  Since life insurance also benefits your family as a whole, the same logic can be applied to life insurance. For those fortunate to have substantial savings, life insurance is an efficient, guaranteed way of passing some of your hard-earned savings to others, whether that is to your extended family, or to your religious organization, or to your favorite charity. It is usually the case that the benefits paid are tax-free.  In particular, if you are a female in excellent health, whole life insurance provides a very good return profile compared to other investments that you could leave to beneficiaries. Home Health Care and Nursing Homes Let’s be clear: the United States has no national strategy to deal with taking care of elderly who cannot take care of themselves. Medicare cannot be considered to be long-term care, period. It is the proverbial “elephant in the room”; we know it exists and know it is an enormous issue, but we don’t discuss it much. The topic is unpleasant at best.  Opinions of people vary greatly; some people abhor the thought of being admitted to a nursing home, and others do not. One thing is certain: the

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costs are enormous if you require skilled nursing care. If you have savings, only the very wealthiest Americans can afford to pay the entire cost. If you have no savings, then the government will pay for your care, which creates stresses on the already-stressed Social Security system. There are no easy answers for a topic that no one wants to discuss. Unfortunately, Medicare, or other combinations of Medicare Advantage and/or Medigap, cannot be considered the same as long-term care for patients. If you require full-time assistance, or if you require skilled nursing facility care, that is an out-of-pocket expense with substantial potential costs. The costs can add up quickly, and ultimately, they can bankrupt a household if you require an extended stay in a nursing home. You most likely know someone like this.  As reported in Forbes magazine, which reported on a study conducted by the Employee Benefit Research Institute (a highly-respected non-profit, non-partisan organization), nursing home residents, on average, lose approximately half (50%) of their savings after six months.   There are insurance solutions. Long-term care insurance, short-term convalescent care, and riders to hospital indemnity plans are three ways that some amounts can be put aside to counter the cost of skilled nursing home facilities. There are annuity-based solutions. For example, recent innovations allow those that require skilled nursing facility care to receive additional annuity payments. The main principle here is that products are changing, and carriers are innovating continuously, in order to address an obvious need.  Long-Term Care Insurance Long-Term Care insurance exists to specifically defray the enormous cost of living in a skilled nursing care facility (nursing home). The benefits would cover, depending on policy, the costs incurred to pay for custodial care and/or skilled nursing care. This can occur at home, or at a facility. The terms of the policy will dictate exactly which benefits you will be able

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to collect, and under what conditions. Generally, you would need to be unable to fulfill two Activities of Daily Living (ADLs), and this would need to be certified by a physician. Long-Term Care insurance (LTCi) has been controversial, for a variety of reasons. Many carriers have decided to stop offering these types of policies entirely. Qualifying for LTCi is decided by the carrier, and anecdotally, the standard required to qualify has become more difficult to meet. Finally, the premiums are subject to change. That has put people in a difficult position. Medicare doesn’t cover custodial care, and only covers skilled nursing care for a limited period. Traditional, stand-alone LTCi can be expensive. Let’s presume, for the moment, that carriers are also aware of this. For example, carriers are reporting that their LTCi enrollments are much lower. They have responded over the past 2 years with a new product: the combination of universal life insurance and something called a “rider,” which adds benefits that would cover custodial care or skilled nursing care, under certain conditions. What is Universal Life Insurance? Note: there are more than ten carriers that offer this combination, so the terms and conditions will vary greatly. It is highly likely that you will require expert advice in order to distinguish the differences, to fit your individual situation. Universal life insurance is a policy that pays a benefit to your beneficiary when you pass away. The premiums will vary, depending on your age, health, biological sex, and financial markets. You can choose to pay more or less, and still keep your policy in force. Extended Benefits & Life Insurance Carriers have added extended benefits to Universal Life insurance, which generally allows the insured person to use the benefits in advance, if cer-

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tain criteria are met. For example, if you cannot perform 2 ADLs or if you have been diagnosed with a terminal condition that will require skilled nursing care, then extended benefits may allow you to collect the benefits, and use those benefits to pay for custodial care or skilled nursing care. If the entire death benefit is not completely used, then it is frequently the case that the remainder is paid to your beneficiary/beneficiaries. Now, this same type of benefit is available in a limited set of term life insurance policies. If this sounds complicated, it is. There are a number of reasons that contacting an expert would be in order. Just like standalone LTCi, the “fine print” regarding the criteria that must be fulfilled in order to receive benefits varies among carriers. In addition, there may be tax implications, depending on the amount of benefits received. After advising a wide variety of Medicare beneficiaries, it is challenging to distinguish among a dizzying number of options. Most importantly, the purchase of any interest in any financial contract (and this is a financial contract) must be appropriate for your individual financial situation. For example, a Certified Financial Planner™ would need to fulfill a fiduciary duty to you, which means that he/she would be prohibited from making a financial recommendation, if it did not fit your situation. Advertisements: Treasure or Trash? A week may not pass by, and certainly not a month: you have received a mailing which promotes lower health insurance costs. Some are legitimate, and unfortunately, some are not.  Turn on the TV, and you get the same thing; commercials about Medicare are everywhere. This is particularly true at the end of every third quarter, and through the end of each calendar year. There are just a few things that you must keep in mind.  First, you should keep all mail from the Centers for Medicare & Medicaid Services (CMS), and mail from The Department of Health and Human Services. It is the official mail from the U.S. Government. The — 128 —


Department of Health and Human Services will send you your Medicare card. If you have a Medicare Advantage or Medigap policy, you should keep all statements from the insurance company that has issued the policy to you. Second, the mail you receive and the advertisements you see, if sent by Medicare plan carriers, are not factually wrong. They are highly regulated. In fact, every presentation slide, every piece or packet of mail, every advertisement has been specifically approved by the CMS. It is almost impossible that a mailing you receive, or an advertisement you see on TV, if created by an insurance carrier, is factually wrong. Think just for a moment: given regulatory oversight, does it make sense that a carrier would intentionally mislead more than 53,000,000 potential enrollees? That would expose the carrier to enforcement which could, potentially, seriously damage and jeopardize the carrier’s business. The bottom line is that much of the sentiment you may have heard is based on emotion, not practical facts. That said, the advertisements are limited because they cannot compare policies offered by different carriers. Third, you should not send in an advertisement that offers reduced medication prices if you have any type of group health plan that supplements Medicare. Remember, you cannot be enrolled in two prescription plans that are deemed to be creditable coverage by Medicare. This includes the prescription plan that is embedded in a group plan, or an MAPD plan, as long as your prescription benefits program qualifies as creditable coverage. If you mistakenly send in this type of advertisement that enrolls you in a separate Medicare Part D, then the Medicare system will cancel your enrollment in your employer-sponsored group health plan. 

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This Happens. Mr. Smith is covered by his retiree group plan, including retiree health benefits. He receives a flyer which suggests that he can save money on prescriptions, and sends it in.  Three months later, Mr. Smith requires medical attention, and pulls out the insurance card he has used for years.  He finds out that he isn’t enrolled in that plan any longer, and he is then responsible for the costs above the amount that Medicare pays.  He only has original Medicare.  You may know someone that sent in this type of flyer, only to find out that the person has the entire Part A and Part B cost sharing to bear as an out-of-pocket expense. This Happens. Agents:  Angels or Devils? Agents may or may not offer a valuable service. The nuances of this book should be no surprise to a highly-qualified agent (it is not clear that all agents would reach the same conclusions as this book, given the same set of individual circumstances).  However, agents do not necessarily offer every plan available in your area, whether it is Medicare Advantage, or Medigap.  Agents may only have permission to offer a limited set of Medigap or Medicare Advantage policies. You, as a consumer, should ask your agent what companies he/she represents.  This is actually quite important, as you can see that Chapter 7 is perhaps the most extensive in this book.  Highly qualified agents will be able to quickly and accurately separate fact from fiction.  Unqualified agents won’t be able to tell you the differences among the different plans described in this book. In addition, unqualified or inexperienced agents may not be familiar with the impact of very high medical costs on your total savings. Young agents may not have lived through the depression, and may not remember the days of double-digit interest rates. 

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Additionally, the insurance agents/brokers that deal with your group plan may not have a background in dealing with Medicare. It is very important that your agent knows Medicare at least to the level of understanding presented in this book. It is insufficient to only know group health insurance, private health insurance, or personal insurance (home / auto).  When you have questions regarding your benefits, or controversies about your claims, then a good agent should be able to help. Agents have special access to insurance companies, i.e. they will dial different numbers to ask questions for their clients. If you are the type of person that doesn’t like dealing with toll-free numbers and being put on hold, then a good, attentive agent will be able to help you. They should be experienced in asking the “right” questions, and as a result, a good agent should be able to explain the answers clearly to you. This Happens. A small business owner is older than 65 but has not yet enrolled in Medicare. His business partner turns 65 next month. They both had been covered using a group health insurance plan. He attempts to qualify for an SEP because he is cancelling his group health plan entirely, so that both he and his partner can enroll in Medicare, along with a stand-alone prescription drug plan, and a Medigap plan. He is told that he must wait, and his Medicare Part B will not begin until the next July. The result is that the small business owner, along with his partner, remain outside the Medicare system, because they do not want to be uninsured. This Happens. This is totally, completely wrong. He has been misinformed by the Social Security Administration. He can cancel his group health plan, and enroll in Medicare Part B, effective the first of the next month. This is a scary scenario, because the small business owner relied on the information from person representing the government.  — 131 —

There is almost no way that an inexperienced person would have been equipped to defend himself in this situation. Only a person fully confident in the exact rules of Medicare eligibility would have been able to be persistent enough to continue to argue the small business owner’s position with the U.S. government, and help him enroll in Medicare Part B without undue delay or penalty. In this case, an agent’s assistance was fully in order.  (Yes, it was me.) One last point about agents: remember that all insurance agents should have a state-sanctioned license. While an agent can make an error, the litigious climate in the U.S. heavily favors people who are Medicare eligible. Very heavily. The CMS sends out people to randomly question agents that are advertising Medicare Advantage plans, to monitor the representations that agents make. Because of that, agents are warned, often, that intentionally misleading statements will subject an agent to sanctions, which can include fines and suspension of his/her license. You, as a consumer, can ask an agent to show you his/her license. There are identification numbers on the license as well. In other words, the idea that an agent is intentionally misinforming you, just to the end of closing a sale, is probably not factually correct. That isn’t to say that agents aren’t compensated for sales, because they are. However, the downside to telling untruths in order to accomplish this is enormous. It may be that he/she isn’t able to explain clearly, but that is on the individual agent, not on agents as a whole. If you are uncomfortable with the advice or answers that you have been given but require professional help, the solution is simple: find another agent. It’s a competitive world, and you will be able to locate one that answers your questions to your satisfaction. Final Thoughts The Medicare system isn’t perfect, and it is unlikely to become perfect in the future. In fact, it is likely to get worse, as a result of demographics (more people turning 65, who live longer), and fiscal reality in the United States. The PPACA has been blamed, physicians are blamed, pharmaceuticals are blamed, and the list is never-ending. The point of this book is — 132 —


not to assign blame, or make judgments about who/what party is right or wrong. There are no immediate solutions regarding how to make the Medicare system better. It is most reasonable to predict that this debate will not be resolved anytime soon.  Medicare isn’t meant to be comprehensive health insurance.  It would be impossible, and we shouldn’t spend too much time to complain about what it should be and what it should not be.  It has little, if anything to do with politics. Even if we all agreed on the priorities and politics of the situation, we can’t get around three fundamental facts: Fact 1.  There are more than 10,000 people turning 65 years old, every day.  They are newly eligible for Medicare, and they are living longer. Those numbers will not decline anytime soon.  Fact 2. If your child or grandchild dreams of becoming a medical doctor, he/she is looking at a) $300,000-$500,000 of educational costs, b) extraordinary regulatory and legal risk, c) being a virtual employee of the federal government, and d) no return on investment at all until he/she is 30 years old (when he starts to pay back the debts). A physician may have no other choice than to charge the Part B Excess. Fact 3. If you invested $1000 in a business for 20 years, took large legal and regulatory risks, your products may not work, and even if they do, you can only sell them at your price for 10 years, how much would you want to make a year from that investment?  How does $50 a year sound per $1000 invested? Unacceptable, right? Congratulations, now you are a partial owner of Merck, one of the world’s largest pharmaceuticals. You would have been much better off if you had invested in a corn farm over that period. Much better. If you mix the three facts together, you get an unsavory soup. In fact, if you consider Fact 2 for a moment, you will be able to understand why the risk of facing the Part B Excess charge is higher than what is commonly believed. If you had $300,000 of debt, would you be in any situation to charge less than the maximum? If that is your grandchild, what would you advise him/her? Well, in this case, that person is a medical — 133 —

doctor. Maybe now, it is obvious why it is pointless to even attempt to find an acceptable solution in the near term. There is a lot of advice out there.  Some of it comes from your workplace. Some of it comes from your colleagues from work, your family, or your friends. Sometimes, it will be correct. I hope so. Unfortunately, that is not always the case. The source of misinformation can even come from official personnel. This is a very difficult topic (i.e. criticizing officials of the government), but one additional point needs to be kept in mind. Employees of the government are human, which means that an individual can be mistaken, and can be motivated by his/her own reasons. A representative of a non-profit governmental agency should not distribute any marketing material that represents an advertisement for a for-profit company. If this occurs, then help your fellow citizen, and report this to the CMS. Someone is responsible for this, and you are being disserved by receiving this information at that location from unlicensed individuals. Uninformed people go to government-sponsored agencies, in search for help, and receive erroneous counsel, or receive applications that were not supposed to be distributed in that forum. This is not disputing the good intentions of the people that are trying to help. However, it has been my experience that the information that has been shared is incomplete, and seniors misunderstand the message they receive as advice. That lack of completeness is just what this book is attempting to address. You should verify these opinions for yourself. Those giving advice, whether they be friends, agents, or your human resources coordinator, may not have complete information. They may have only been through a limited set of circumstances. In other words, their situation may be different from yours. The things that your friends face, you may not. The things that you face, your friends may not. They can be health-related. They can be related to your financial flexibility, or your domestic situation.  Finally, this book has pointed out that the Medicare system itself may change, and can reasonably be expected to change.  There are reasons

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that this book recommends that you take control of the situation. The unequivocal good news is that the rules are largely constructed to protect the consumer, and if you know the rules well, then a solution is likely to be found. The forces beyond your control may deteriorate;  they have no simple solution, no easy answers. It doesn’t matter what your political affiliation or religion is, there are fewer people paying into the Social Security system, and more people who are eligible for Medicare benefits. You may have devoted your career to an employer, but that employer may no longer be viable, or it may face challenges that must be deemed a higher priority. The lower level of economic activity and the rising cost of benefits for active employees are a couple of the largest of those forces. We will not be able to resolve any such debate easily. The only certainty is that the person that will be affected is you, the Medicare beneficiary. The choices can be confusing, and it doesn’t matter if you are rich or poor.  In any financial situation, you can do better by knowing more. Hopefully, this book has given you some more knowledge, so you are not as worried that you don’t know something. This book isn’t perfect; no individual book can possibly cover every scenario. There are too many exceptions, too many individual cases to possibly address them all in one place. Nevertheless, if you follow these guidelines, and avoid the pitfalls, then you can Maximize Your Medicare. ***

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GLOSSARY  Activities of Daily Living (ADLs): There are six ADLs.  They are eating, bathing, dressing, toileting, transferring (walking), and continence.  Long term care insurance may cover a patient if it is documented that he/ she cannot conduct three ADLs. Allowed Charge:  The amount Medicare will compensate a medical provider for services rendered.  A prescribed amount, called the Allowed Charge.  Any amount above the Allowed Charge is called an excess charge. Annual Election Period (AEP):  Also known as the Annual Coordinated Election Period.  In 2018, the Annual Election Period (AEP) runs from October 15, 2018 through December 7, 2018.  Medicare Advantage and Medicare Part D plans can be changed without restriction during this time. Assignment of Benefits:  The compensation given by the Medicare system to a medical provider.  Under a PFFS, the medical provider must accept Medicare’s Assignment of Benefits on a case by case basis.  Failure by the medical provider to accept the Assignment of Benefits within a PFFS structure will result in no benefits paid from either Medicare or the PFFS plan. Coinsurance:  A percentage of administered services that you, the insured, must pay.  For example, if the coinsurance percentage is 20%, then your insurance policy will pay for 80%, and you are responsible for 20%. Copayments:  A fixed dollar amount, which you must pay.  For example, stand-alone Part D plans have fixed amounts that you, the insured, must pay, for a given medication. Cost sharing:  The combination of deductibles, coinsurance, and copays under a Medicare Part D, Medicare Advantage, or Medigap plan.

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Coverage Gap: Otherwise known as the “donut hole.”  For 2018, this begins when your total out-of-pocket expenses (deductible plus copays) reach $3,750, and lasts until your total out-of-pocket expenses reach $5,000. Credible Coverage: The term is used to describe prescription drug plans. If you have creditable coverage, there will be a certificate, or a page, in your Summary of Benefits that describes your group plan. That certifies that your plan meets certain criteria established by the CMS. If you discontinue coverage (either voluntary or involuntary) under a plan that qualifies as creditable coverage, then you may return to original Medicare, or select Medicare Advantage, Medigap under a Special Election Period (SEP). In addition, you can also select a stand-alone Prescription Drug Plan (Medicare Part D). If your plan loses creditable coverage status, then this is another SEP, and you are entitled to all changes under SEP privileges. Custodial Care:  Care related to Activities of Daily Living (ADLs). Note that this is NOT the same as Skilled Nursing Care. Therefore, it is not covered by original Medicare.Custodial care is not covered by Medicare Advantage plans or Medigap plans. Deductible:  A fixed-dollar amount which you must pay before you receive insurance benefits.  For Medicare Part B, the Part B deductible is $183.00.  This is subject to change by Medicare or your insurance company. The easy way to remember deductible is that you are first in line to pay bills up to the Deductible amount. Then, after the Deductible amount is satisfied, you will begin to receive insurance benefits. Durable Medical Equipment (DME): DME are covered by Medicare Part A, with cost sharing.  Medicare Advantage and Medigap plans have cost-sharing arrangements which depend on the plan.  Note: needles for insulin injection are part of DME. End Stage Renal Disease (ESRD):  Kidney failure that requires dialysis or transplant.  Kidney failure which is not ESRD can occur.  ESRD is a specific condition with a percentage failure rate which must be doc— 138 —


umented for Medicare purposes as well under VA benefits purposes. ESRD patients can purchase Medigap, but are generally not allowed to purchase a Medicare Advantage (MA) plan. Extra Help program:  Federal program which offers financial assistance, to those that qualify, to defray prescription costs, including Part D premiums, deductibles, and copays.  Extra help beneficiaries have no restriction in changing their prescription drug plan within a calendar year.  Qualification status can be changed by the Social Security Administration (SSA). Formulary:  A list of approved drugs issued by insurance companies.  A formulary can change throughout the year, with restrictions imposed by the CMS.  Every medical condition must have at least 2 medications in its formulary suitable for use, as determined by the CMS. General Enrollment Period (Medicare General Enrollment Period): Runs annually from January 1 through March 1 each year, for coverage to begin July 1 of that year. Health Savings Account (HSA): A bank account, which can best be considered a “Health Expense IRA.” In order to open an HSA, you must be enrolled in a High Deductible Health Plan (HDHP). Funds in an HSA can be used to pay for allowable medical expenses, as defined by the U.S. Internal Revenue Service. HMO (Health Maintenance Organization): An organization that provides medical services via contract with member medical providers and facilities.  A primary care physician (PCP) must be selected by the policyholder, and future consultations are approved via referral.  If services are received from physicians or facilities, then the HMO will not provide benefits. Home Health Care:  Home health care services are offered by privately-run agencies, sometimes in conjunction with skilled nursing care facilities.  Patients receive custodial care at their home on an hourly or daily basis.  Medicare does not cover any costs associated with home health care unless it is accompanied by skilled nursing care according to Medicare Part A. — 139 —

Initial Coverage Election Period (ICEP): A one-time event when a beneficiary can enroll in a Medicare Advantage plan. It ends the day before a person is eligible for both Medicare Part A and Part B, for the first time, or the last date of the individual’s Part B initial enrollment period. Initial Election Period (IEP): A seven-month period when most people can first enroll in Medicare Part B and Medicare Part D, beginning three months prior to the first date a beneficiary can be eligible for Medicare Part B and Medicare Part D, and ending three months after the last date of the month a beneficiary can be eligible for Medicare Part B and Medicare Part D. Long Term Care insurance (LTCi):  Insurance which covers costs that is used to defray costs when the beneficiary cannot perform 3 ADLs (Activities of Daily Living).  Low Income Subsidy(LIS):  See Extra Help program. Medicare Advantage:  Plans that are certified by the CMS on an annual basis.  Subject to enrollment rules, with exceptions, called Special Election Periods.  May or may not include prescription drug benefits.  Restrictions apply with respect to medical provider.  Cost sharing terms and conditions are subject to change on an annual basis with the approval of the CMS. These plans must be, on average, superior to original Medicare. Important note: that does not mean that each specific benefit in a particular Medicare Advantage plan must be superior to original Medicare. It means that the plan, as a whole, must be, on average, superior to original Medicare. Medicare Advantage Disenrollment Period:  January 1 – February 14.  You can cancel any MA, and return to original Medicare.  In addition, you can also purchase a stand-alone prescription drug plan (Medicare Part D) at this time. Medicare Advantage Prescription Drug (MAPD plan): A type of Medicare Advantage plan.  It combines hospital insurance, health insurance, along with prescription drug benefits.  It cannot be used with a stand-alone prescription drug plan (PDP, also known as Part D). — 140 —


Medicare Part A: Hospital insurance as defined by the Centers for Medicare & Medicaid Services (CMS).  Includes Skilled Nursing Facility Care, Home Health Care, and Hospice services. Medicare Part B:  Medical insurance as defined by the Centers for Medicare & Medicaid Services (CMS).  Includes services administered by physicians. Medicare Part C:  Also known as Medicare Advantage (MA).  Medicare Advantage plans include HMOs, PPOs, PFFS, POS, and HMO-SNPs.  Medicare Advantage plans replace original Medicare, and insurance carriers process claims (except in the case of POS). Medicare Part D:  Also known as stand-alone prescription drug plans (PDP).  Beneficiaries cannot have prescription coverage from two sources.  Prescription coverage is subject to a plan formulary.  Can be changed annually without restriction during the Annual Election Period (AEP). Medigap:  Also known as Medicare Supplement, Medicare Supplemental Insurance.  Plans are labeled with letters A-N. The terms and conditions of every plan are standardized among carriers, and will remain in effect, unchanged, as long as the policyholder continues to make premium payments. Military Disability:  Complicated system which requires separate application process from Social Security disability.  Partial disability categorization is possible.  VA-supplied medical insurance and prescription benefits available. NOTICE Act: The formal name is the Notice of Observation Treatment and Implication for Care Eligibility Act. The NOTICE Act requires the hospital to inform a patient whether he/she status in a hospital is outpatient (observation) or inpatient. Original Medicare: Medicare Part A and Medicare Part B, in combination, are called original Medicare. PCP (Primary Care Physician):  The physician that you identify if you select a Medicare Advantage HMO.  Your PCP must provide a referral if you require services from a specialist. — 141 —

PFFS (Private Fee For Service): A type of Medicare Advantage plan that requires case-by-case approval by the medical provider.  The medical provider must agree to accept the Medicare-allowed charge as full payment.  A PFFS is the only Medicare Advantage plan that allows a Medicare beneficiary to also enroll in a stand-alone prescription drug plan (Medicare Part D). POS (Point of Service):  A type of Medicare Advantage plan that has a primary care physician that coordinates in-network referrals.  Services received from in-network providers are coded, billed, and coordinated by the PCP.  Referrals outside the network are allowed, although the cost sharing arrangement may not be for full payment of services.  PPO (Preferred Provider Organization):  A type of Medicare Advantage plan that allows participants to receive services from in-network and out-of-network providers.  The number of member providers in a PPO is usually larger than the number of member providers in an HMO, thereby allowing for greater freedom of choice in selecting physicians and facilities.  Services received from out-of-network providers have costlier cost sharing terms and conditions than services received from in-network providers.  Short-Term Convalescent Care Insurance:  Insurance which can be purchased to provide benefits for skilled nursing home care and, in certain cases, custodial care.  Beneficiaries can choose whether or not benefits will include custodial care at his/her home.  Limitations exist on the length of time that benefits can be received by the beneficiary. Skilled Nursing Care: This is a defined term by Medicare.  Services must be ordered by a physician, and delivered by a registered nurse (RN) or a licensed practical nurse (LPN).  Services must be deemed to be reasonable and necessary for the treatment of illness or injury.  Skilled Nursing Care Facility (SNF):  Also known as a nursing home.  A facility that delivers skilled nursing care.  Costs are covered by Medicare Part A only after being admitted inpatient at a hospital for at least 3 days.  Long Term Care insurance can be used to defray costs incurred at a skilled nursing care facility. — 142 —


Social Security Administration (SSA): Governmental agency that determines Medicare eligibility, and Extra Help program qualification.  Social Security Disability Insurance and Supplemental Security Income:  Benefits paid to those that require assistance due to disability.  Applications for these benefits are difficult to obtain, and legal representation is usually required. Special Election Period:  There are Special Election Periods (SEP), in which you can either return to original Medicare or enroll in a Medicare Advantage (MA) plan.  In addition, you can appeal for an SEP as well, if the situation does not fit any of the predetermined categories.  A description of the SEPs is listed in Chapter 4. Summary of Benefits: Document that details cost sharing details with a health insurance policy. You should either a) receive one annually, or b) be able to request this from your insurance company and/or human rights coordinator at an employer. Details will include terms and conditions of enrollment rules, cancellation rules, deductibles, copayments, and premiums. You should keep the most recent copy for reference. Term Life Insurance:  Life insurance that pays a death benefit to the named beneficiary upon the death of the insured, as long as the date of death occurs before or on the date of expiry.  If the insured survives beyond the date of expiry, then the insurance ends, and the insured become uncovered.  There is usually no cash value associated with Term Life Insurance. Whole (Permanent) Life Insurance:  Life insurance that pays a death benefit to the named beneficiary upon the death of the insured.  Coverage does not expire, regardless of attained age of the insured.  Premiums may vary, depending upon the terms and conditions of the policy.  Whole Life Insurance may build cash value which may accrete based on investment performance.

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BIBLIOGRAPHY  America’s Health Insurance Plans (AHIP). “Trends in Medigap Coverage and Enrollment, 2011.”  2012. MedigapPremiums/index.shtml Andrews, Michelle.  2012, August 20, “Health Law Prompts Review Of Some Medigap Plans; Defining Who Gets Dependent Status,” Kaiser Health News, Graham, Judith.  2012, September 21, “The High Cost of Out-Of-Pocket Expenses,” The New York Times, http://newoldage.blogs.nytimes. com/2012/09/21/the-high-cost-of-out-of-pocket-expenses/ Marchand, Ashley, 2012 September 27, “Stakeholders:  Medicare Should Cover Care Received in ‘Observation’,”  California Healthline, Centers for Disease Control and Prevention, 2011, “2011 National Diabetes Fact Sheet,” Centers for Medicare & Medicaid Services, 2016, Medicare and You, Centers for Medicare & Medicaid Services, 2016, Choosing a Medigap Policy:  A Guide to Health Insurance for People with Medicare, https:// Centers for Medicare & Medicaid Services, 2011, “Annual Release of Part 0044 National Average Bid Amount and other Part C & D Bid Related Information,” 

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Centers for Medicare & Medicaid Services, “Medicare and Other Health Benefits: Your Guide to Who Pays First,” Centers for Medicare & Medicaid Services, Fact Sheet: Two Midnight Rule, Centers for Medicare & Medicaid Services, 2011, November, “Understanding Medicare Enrollment Periods (Revised November 2011)” Centers for Medicare & Medicaid Services, 2012, “Your Guide to Medicare Special Needs Plans (SNPs),” Amy S. Kelley, Kathleen McGarry, Sean Fahle, Samuel M. Marshall and Qingling Du, et al., 2012 September, “Out-of-Pocket Spending in the Last Five Years of Life,” Gleckman, Howard, “A Nursing Home Stay Can Ruin Your Finances,” Forbes, 2012 June 22. Karoub, Jeff. 2012, June 14, “Michigan House OKs changes for teachers’ retiree health care, leaves retirement plan alone,” Crain’s Detroit Business, michigan-house-oks-changes-for-teachers-retiree-health-care-leaves-retirement-plan-alone# Marcum, Diana.  2012, July 12.  “Stockton retirees sue to stop city from cutting health benefits,” Los Angeles Times, http://articles.latimes. com/2012/jul/12/local/la-me-stockton-retirees-20120712. Marzilli Ericson, Keith M. 2012, September. “Consumer Inertia and Firm Pricing in the Medicare Part D Prescription Drug Insurance Exchange,” NBER Working Paper No. 18359.

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National Kidney Foundation®,   “ESRD Medicare Guidelines,” http:// pdf U.S. Census Bureau, Population Bureau, 2008,  “U.S. Population Projections.” United States Government Publishing Office, 2015, ‘Notice of Observation Treatment and Implication for Care Eligibility Act, https://www. United States Government Publishing Office, 2015, “Bipartisan Budget Act of 2015,” pdf/BILLS-114hr1314eah.pdf Veterans Administration, “Veterans Health Benefits Guide,”    http://

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ACKNOWLEDGEMENTS  There are many to thank when considering the completion of this book. In a weird way, their examples have imposed pressure on me to make sure this book is the best that it could be. First, thanks to my friend Charles Park, who has advised me on important aspects of this book, and more importantly, on life, through his understated example. He has encouraged me to write a book.  I doubt this was the topic he had in mind, but nevertheless, his encouragement and friendship has been consistent and unwavering. Second, I am indebted to Ani Cho Stone (I knew her as Ani Cho).  She has been my friend since she was just a few years old. She designed the book cover.  Ani Cho Stone is a freelance designer with over 15 years of experience creating digital solutions and building brands online. She collaborates with clients to design websites, online promotions and marketing materials. She has done work for Starbucks and Vitaminwater®, among others. You can learn more about her and see samples of her work at I would recommend her without reservation.  Third, and perhaps most importantly, I want to thank Jeannie Shene of Imlay City, Michigan, who faces formidable challenges of her own. Nevertheless, she has displayed unselfishness, strength, and courage by putting her aging parents’ well-being first, without an outward hint of self-pity, although she may have had ample reason. Maybe you are courageous like her. I sincerely hope so.

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INDEX  AEP. See Annual Election Period Annual Election Period, 40, 41, 50, 51, 67, 83, 95, 112, 127, 142, 146 benefit period, 19, 21 Birthday Rule, 83 COBRA, 11, 12 coinsurance, 142 Coinsurance, 68 collective bargaining agreement, 104, 117 copayment, 19, 68, 81, 92 copays, 17, 20, 21, 41, 42, 56, 57, 71, 80, 105, 121, 142, 143 deductible, 17, 19, 21, 25, 28, 29, 31, 32, 40, 44, 46, 60, 67, 68, 69, 71, 74, 79, 80, 87, 92, 98, 99, 103, 104, 105, 142, 143, 144 employer-sponsored plan. See Group Insurance Employer-sponsored Plan Change, 52 Five Star Plan, 52 formularies, 40, 54 General Election Period, 13 Health Maintenance Organization, 53, 144 HMO. See Health Maintenance Organization HMO-SNP. See Special Needs Plan home health care, 144, 146 hospice, 19, 146 — 151 —

improvement standard, 17 late enrollment penalty, 6, 12, 13, 14, 36, 97 Late Enrollment Penalty, 18 Life Insurance, 129, 148 life qualifying event (LQE), 94 Limited Income Subsidy, 20, 52 long-term care insurance (LTCi), 131, 132 Loss of Creditable Coverage, 52 Medicaid Status Change, 52 Medical Loss Ratio, 84 Medicare Advantage, 20, 32, 48, 51, 53, 54, 55, 56, 57, 58, 59, 61, 62, 65, 68, 73, 76, 77, 78, 80, 93, 98, 99, 102, 111, 115, 117, 122, 123, 127, 131, 133, 135, 137, 143, 145, 146, 147, 148 Medicare Advantage Initial Coverage Election Period, 48 Medicare Advantage Plan Cancellation, 52 Medicare Annual Disenrollment, 52 Medicare Initial Enrollment Period, 9, 13, 32, 36, 64, 127 Medicare Part A, 8, 10, 18, 19, 20, 21, 23, 36, 56, 64, 65, 67, 71, 121, 123, 143, 144, 146, 147 Medicare Part B, 8, 9, 10, 13, 27, 30, 32, 33, 48, 53, 55, 65, 68, 69, 74, 77, 79, 80, 91, 92, 96, 97, 103, 113, 114, 119, 123, 136, 137, 146 Medicare Part D, 36, 37, 42, 44, 45, 46, 51, 52, 53, 55, 65, 67, 72, 99, 110, 111, 117, 121, 123, 134, 142, 143, 145, 146 Medicare Savings Program (MSP), 14

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Medicare supplement. See Medigap Medicare-allowed charge, 19, 29, 31, 74, 122, 146 Medigap open enrollment period, 64, 65, 66, 72, 73, 79, 84, 127 MIB Group, Inc, 127 moving, 51 network, 53, 54, 55, 57, 58, 59, 72, 73, 78, 102, 147 NOTICE Act, 23 nursing home. See skilled nursing facilities observation status, 23 original Medicare, 4, 20, 39, 51, 52, 56, 57, 67, 68, 71, 78, 81, 83, 96, 115, 135, 143, 145, 146, 148 Other prescription drug assistance, 52 out-of-pocket expenses, 20, 31, 41, 57, 61, 76, 80, 102, 115, 119, 142 Part B Excess, 31, 32, 54, 74, 77, 80, 98, 115, 122, 138 PCP. See Primary Care Physician PFFS. See Private-Fee-for-Service Pharmacy assistance program, 52 Point of Service, 53, 54, 147 POS. See Point of Service PPO. See Preferred Provider Organization Preferred Provider Organization, 53, 147 Premium, 35, 47 Primary Care Physician, 53, 54, 146 Private Fee-for-Service, 53, 54

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Qualified Individual Program (QI), 14 Qualified Medicare Beneficiary Program (QMB), 14 Qualified State Pharmaceutical Assistance Program. See Pharmacy assistance program Skilled Nursing Facility, 19, 22, 25, 52, 146, 147 Social Security disability, 10, 146 SPAP. See Pharmacy assistance program Special Election Period, 44, 51, 54, 72, 99, 101, 113, 143, 148 Special Needs Plan, 53, 54 Specified Low-Income Medicare Beneficiary Program (SLMB), 14 TFL. See Tricare For Life Tricare For Life, 109, 112 Two-Midnight Rule, 24 Universal Life insurance, 132 Veterans Administration, 10, 108, 109 vision, 102 whole (permanent) life insurance, 128

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EXPERTS’ ADDENDA  This special section is intended for those with academic backgrounds or practical experience in financial and/or business matters. Or the perversely curious. Insurance Is An Option In order to understand the conclusions contained in Maximize Your Medicare, it is important to understand that insurance is, at the end of the day, an option, much like a put or a call on a stock. The definition of an option may be difficult to grasp. An option is the right to buy or sell a product (for example, a stock) for a pre-specified price, if a certain set of conditions are met. Many people will understand what a put or a call option is, from the financial markets. The key point is that the value of the contract increases rapidly under certain conditions. A call option on a stock increases in value greatly as the underlying stock approaches the strike price. In a very similar way, the value of health insurance (including Medicare) also rises dramatically if you incur medical costs, because you receive benefits which can exceed your premiums by a great deal. Health Insurance Is Different Health insurance is not the same thing as auto insurance or homeowner’s insurance. Nevertheless, this is the kind of comparison that you can hear in every coffee shop, in every corner of the nation.  Comparing health insurance to auto insurance is like comparing apples to oranges. They are both a type of fruit, and that is where the similarity ends. It is a fundamentally incorrect comparison to make. Why? Say you get in a car accident, and you completely wreck your car, but walk away unscathed. What is the cost to you? Do you know? Open a — 155 —

Kelley Blue Book, and you will be able to determine the salvage value of your car within hundreds of dollars. You can replace your car with an almost-exact copy, at a well-defined price. On the other hand, imagine that you become seriously ill, and are diagnosed with a disease. What are your costs then? Can you predict the price of recovery? You cannot predict when those costs will cease. You cannot predict if you can go back to work to repay those new, unknown costs. You cannot calculate it, and your estimate can be wrong by tens of thousands of dollars. The cost can bankrupt your household, and the outstanding liability will make you indebted to the government for the remainder of your life.  In other words, the downside of not protecting yourself in case you become seriously ill is many, many, many times worse than getting into a car accident. You cannot estimate the maximum loss of money, time, and well-being if you become ill. And the older you get, the more extreme it becomes, because the likelihood of becoming seriously ill is greater. Options Are Priced Using Probability Let’s get back to the comparison between health insurance, Medicare, and options from financial markets. Options are financial contracts that have a mathematically-derived theoretical value. For financial market professionals, this is the widely known Black-Scholes formula. For the purposes of this book, the calculation itself isn’t important, but the formula has intuition which we will address here. If you look at the Black-Scholes formula, it is largely dependent on probability. To keep it relatively simple, people are familiar with the “bell curve.” This is what statisticians would call a graph of the “standard normal probability” curve. Creating this curve requires certain assumptions. An important assumption is that every data point is independent, i.e. the results of any previous results do not affect the probability of future results. In theory, that sounds right.

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In practice, however, it is flawed. Why? It isn’t independent if you have specific information about your individual circumstance. The implication of this fact on health insurance and Medicare is powerful. When you are 64.9 years old, and preparing to consider your Medicare configuration, you will very likely be aware of individual or family health history to some degree. The sellers of health insurance (carriers) are not allowed to adjust the price, for any reason, even if you have specific information. What are some examples of “specific information?” Medical history and family history fits this description. Let’s look at it from the seller’s (carrier) point of view. If you are the seller, and you will be required to pay benefits if your customer (you) incurs large medical bills, and you knew this in advance, wouldn’t you want to charge that customer a higher premium? In addition, the liabilities that you would incur are potentially unlimited. Wouldn’t you want to charge that customer more? The intuitive answer would be yes, but the fact is that regulations make this impossible when you first turn 65 years old. That means that if you have a pre-existing medical condition, or a medical history that makes it very likely that you will require ongoing expensive, medical care, that the price of Medicare Advantage or Medigap are, if anything, too low. You don’t have to know anything about insurance in order to understand this. Just compare Medicare to the price of health insurance for a 64-year old: high-quality health insurance, which would still be inferior to Medicare, costs more than $1000/month. Everyone is “Short” an Option In financial markets, you can benefit, as an investor, if any financial asset goes up OR down (that is possible). You can buy or sell an option, a financial contract, that increases in value if the price of gold increases. In addition, you can also buy or sell a set of securities that go up if the price of gold decreases.

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As your healthcare costs increase, your net worth (not to mention your ability to make money), will most likely decline. The extent of decline has no limit in extreme scenarios. That is very similar to being “short” an option, much like the investor that is short the price of gold, which is damaging to that investor if the spot price of gold increases. Everyone, irrespective of financial resources, is “short” this option, i.e. everyone is getting older, and the probability of requiring medical care is increasing with time. The bottom line: buying health insurance is like buying an option at a regulated price. That option protects your household net worth, because it allows you to not spend your savings/investments, at the time that you require medical services. Sources of Volatility Back to the Black-Scholes formula. The value of a put or a call option increases as volatility increases. In simple terms, that means if there is a wider array of outcomes possible, the shape of the bell curve will be different (but it will be symmetric). When considering the value of Medicare and healthcare cost planning, the volatility increases under a wide variety of situations. Let’s take a look at a few, the value of health insurance, and the specific case of Medicare. Substantial assets. If you have substantial assets, you can use this method of thinking to understand other conclusions. Since health insurance will continue to pay benefits to the policyholder, irrespective of amount, that means that the wealthier the person is, or the more assets that person has, the actual financial value of Medicare or health insurance contract increases. Why is that? The reason it’s simple: you have more to lose (which is the same thing as saying that your volatility is higher). Thus, the contracts protect more, and are therefore, more valuable. Period. Medical and family history. Let’s say you are a female, and your mother, grandmother, and sisters have been afflicted with breast cancer. Can you say that you are the “average” case? No. Put another way, this female is

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subject to a wider variety of outcomes, her volatility of outcomes is higher. The price of health insurance is substantially more valuable to you, and the carriers cannot adjust the selling price to reflect this fact. Financially restrained. For those that need to save every dollar, Medicare Advantage has all the advantages listed above, and another important one. Every Medicare Advantage plan must always include an annual out of pocket maximum limit. The value of the option is high, and when coupled with financial assistance or Medicare Advantage plans with no additional premium, the cost is very, very low. The bottom line: health insurance, especially under the Affordable Care Act (if your state participates in Medicaid expansion), and certainly under Medicare, is, if anything, and underpriced way to protect your assets, irrespective of the level of your household net worth. Comparing Apples to Apples Much of the confusion regarding Medicare is that there are a wide variety of choices and wide differences in price. Much of the logic and analysis of how to approach Medicare is actually the result of thinking about comparing the options that you enjoy (due to rules of Medicare) and comparing the benefits that you can receive, for a particular price. Let’s take Medigap Plans C and F. If you look at the grid, they differ in only one regard: the Part B Excess Charge. Under Plan C, the patient/ beneficiary is responsible for the Part B Excess Charge. Under Plan F, the carrier will pay for the Part B Excess Charge. If you put the two plans together, then it should be self-evident: Plan F is slightly superior in coverage, since the language is identical in every other respect, down to the last letter. Now the question will be if the difference in premium is “worth it.” It should be clear that if you can purchase both plans at the identical price, then Plan F will provide a slightly better set of benefits for no extra cost, when compared to Plan C. Usually, Plan F is more expensive than Plan C. Depending on how much the extra coverage is “worth,” Plan F may or — 159 —

may not be a better alternative. How do you decide what it is “worth?” Just re-read this chapter from the beginning: if you are subject to more volatility (due to your health situation or financial results), then the extra coverage is worth more to you. It is as simple as that. You can continue this process to consider every aspect of benefits that you receive. Comparing Medicare Advantage plans is notably more difficult. Recall from an earlier chapter, Medicare Advantage is an annual contract, which means the exercise of comparing “apples to apples” will change every year. It is practically impossible to believe that this situation will cease to exist. Why? The funds from the CMS change every year, and there are multiple competitors (carriers) trying to win more customers (you) every year. Medigap vs. Medicare Advantage Revisited Many say that it is very difficult to determine if Medigap or Medicare Advantage is superior. Earlier in this book, it is stated that the coverage of Medigap is superior due to the cost-sharing details are superior, and cannot be changed over time. We can use the information from this section, to help compare Medigap to Medicare Advantage. Let’s say you have two Agreements, and you already know that the language of Agreement 1 will not change through time, but under Agreement 2, the other party can change the language. Let’s now compare the prices, and even if the benefits are identical, it should be clear that Agreement 1 is worth more than Agreement 2. In this simple example, Agreement 1 is Medigap, and Agreement 2 is Medicare Advantage. Remember that you have the unrestricted right to change from Agreement 1 (Medigap) to Agreement 2 (Medicare Advantage), but not vice versa. That is because if you attempt to change from Medicare Advantage to Medigap, carriers can deny your application, and it is their sole discretion. Further, you will be required to wait until the Annual Election Period, because you cannot cancel a Medicare Advantage plan to enroll

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in Medigap during the middle of the year (unless you qualify for a Special Enrollment Period, described earlier). In short, you can see that this option to change would mean that Agreement 1 should be more expensive than Agreement 2. A buyer should be willing to pay for the right to change between the two configurations, all else equal. That is not to say that all else is equal. For many, the difference in premium is not “worth it,” because that extra premium needs to be used for some other purpose. That is not to be confused with the idea that there isn’t a good reason for that price difference. The previous paragraph illustrates that there is flexibility to change from Medigap to Medicare Advantage, and that worth money, it isn’t worthless. The question isn’t “if there is a difference.” Rather, the question is “is the difference worth it?” The stunning decision made by many: paying more for Agreement 2 when compared to Agreement 1. Nevertheless, this happens in many locations, where the most expensive Medicare Advantage plan is selected, instead of Medigap. As you can see by this Addenda, this configuration contradicts the common-sense reasoning used here.

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ABOUT THE AUTHOR  Jae W. Oh, MBA, CLU®, ChFC® is a Certified Financial Planner™, Chartered Life Underwriter®, and a Chartered Financial Consultant®. He is an expert contributor to a website powered by the nation’s second largest carrier of Medicare plans, Humana Inc., titled MyMedicareAnswers. com, and frequent public speaker to large and small groups, including colleges, companies, library systems, and senior centers. He has a Master’s Degree in Business Administration (MBA) in Accounting and Finance from the University of Chicago, and a Bachelors of Arts (BA) degree in Economics and Political Science from the University of Michigan, Ann Arbor. Consulting services to individuals, businesses and governments are available.  License numbers, accreditations, and references are available upon request.  Certified Financial Planner™ is a trademark of the CFP Board. Chartered Life Underwriter (CLU®) and Chartered Financial Consultant (ChFC®) are trademarks of The American College. Website: Financial Planning Website: Email: Twitter: @MaxYourMedicare Facebook: Maximize Your Medicare Pre-Medicare:

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Maximize Your Medicare (2018 edition)  
Maximize Your Medicare (2018 edition)